Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, are 
not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the speech therapy services. 
 
You asked the Plan to pre-approve the speech therapy services. You say that the enrollee has made major gains 
with a speech pathologist and would benefit from continued speech therapy to recover from a subarachnoid 
hemorrhage. The Plan denied your request. The Plan says six visits are reasonable based on the enrollee's 
condition, and status. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the speech therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee does not have capacity to respond to 
speech therapy. Unique input from a skilled therapist is not necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the speech therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the speech therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopy, surgical, gastric restrictive procedure; 
longitudinal gastrectomy (43775). 
 
You asked the Plan to pre-approve a laparoscopy. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that this service is covered when the enrollee has a 
body-mass-index (BMI) greater than or equal to 35 kg/m2. 
 
We looked at the file and Medicare rules. In this case the enrollee's most recent medical records show a BMI 
lower than 35 kg/m2. Based on this information, we decided that Medicare rules for coverage of a laparoscopy 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a laparoscopy, surgical, 
gastric restrictive procedure; longitudinal gastrectomy (43775).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
enrollee does not meet the coverage criteria for Prolia. Our physician reviewer found the Plan requires a trial of 
Zoledronic acid before they will approve the requested drug. The enrollee has not tried and failed the required 
drug. Our reviewer also found that the documentation does not support that Zoledronic acid would likely be 
less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555, L8679). 
 
You asked the Plan to pre-approve an electrical stimulator. You say that the goal is to help alleviate the 
enrollee's current pain and increase the enrollee's ability to participate in day-to-day activities with reducing or 
alleviating the need for use of opioid medications. You also say it was determined by the provider, given the 
above information that the enrollee would be an excellent candidate for the PENS (Percutaneous Electrical 
Nerve Stimulation) unit to help with chronic pain and reduce the use of narcotics. The enrollee is likely to 
obtain significant therapeutic benefit from the neurostimulator treatment. The neurostimulator will aid in the 
ability to participate in normal activities of daily living and increase blood flow to the affected areas resulting 
in a reduction of pain. The enrollee has tried and failed conservative care and medication therapies. The Plan 
denied your request. The Plan says electro-acupuncture devices used for stimulation of auricular acupuncture 
points are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electrical stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that the requested percutaneous implantation of a 
neurostimulator electrode array/auricular stimulator (L8679) at issue in this case meets all Medicare criteria for 
medically reasonable and necessary and safe and effective for the enrollee. The enrollee's medical record must 
contain sufficient documentation of the enrollees medical condition to substantiate the necessity for the type 
and quantity of items ordered and for the frequency of use or replacement (if applicable). The information 
should include the enrollees diagnosis and other pertinent information including, but not limited to, duration of 
the enrollees condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc." 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous implantation of neurostimulator electrode array; peripheral nerve 
(excludes sacral nerve) (64555, L8679).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF is reasonable and necessary for the 
treatment of the enrollee's illness. The Plan denied your request. The Plan says the SNF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as residential care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical procedure codes 43261 and 43277 rendered on 
September 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 43261: 
 
Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple 
 
 CPT 43277: 
 
Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of 
biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each 
duct 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 43261 and 43277 has a 
bundled relationship with CPT 43274, which was performed on September 28, 2022 and was billed and paid by 
the health plan. A 59 modifier is allowed to unbundle the relationship, providing the medical records support 
the use of the modifier.  In this case, the medical records do not validate that CPT 43261 or CPT 43277 were a 
distinct separate procedure, therefore it is inappropriate to use the 59 modifier on CPT 43261 or CPT 43277 
and no additional payment is allowed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical procedure codes 43261 and 43277 rendered on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee underwent hip fracture 
repair and remains dependent for activities of daily living. She is dependent on caregivers and there is no 
documentation that the caregivers cannot use a manual wheelchair. The PWC is therefore not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Life2000 device is not medically 
necessary. The Life2000 device is not a true ventilator, because it is not capable of providing full ventilatory 
support. Its primary intended use is during activity, and not to treat chronic carbon dioxide (CO2) retention 
during sleep. There is inadequate evidence of its safety and effectiveness in the treatment of chronic obstructive 
pulmonary disease (COPD).  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and dehydration. 
Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the records do not 
show that the enrollee will be able to participate in the intensity of 3 hours of daily therapies, there has been a 
progressive decline in function, and it is not reasonable to expect to significantly improve in a short time. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and 
five days a week, or 15 hours over seven consecutive days 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not specify any acute functional or clinical status change thus professional assessment by 
skilled nurse or therapists would not be medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the folding walker (E0146), tub stool or bench (E0245), and 
transcutaneous electrical nerve stimulation (TENS) device (E0730) purchased on January 27, 2022. 
 
You asked the Plan to pay for the folding walker, tub stool or bench, and TENS device. You say that you 
would like to be reimbursed for these items. The Plan denied your request. The Plan says the folding walker 
and tub stool or bench were not obtained from a medical supplier. The Plan also says their first decision to deny 
coverage and/or payment for the service was right. 
 
 
 The Plan must follow Medicare rules. Medicare rules say to receive payment for Medicare-covered items or 
services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the 
Medicare program. The rules also say that DMEPOS is covered only when there are both a physician order and 
proof of delivery.  
 
The providers that you purchased the folding walker and tub stool or bench from are not enrolled in Medicare, 
and are not eligible for payment. The record also does not contain a valid physician order for the TENS device 
provided in this case. Specifically, a written order and proof of delivery are both needed for a TENS device to 
be covered by the Plan. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the folding walker 
(E0146), tub stool or bench (E0245), and transcutaneous electrical nerve stimulation (TENS) device (E0730) 
purchased on January 27, 2022.