Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan (78452). 
 
You asked the Plan to pre-approve a SPECT scan. The Plan denied your request. The Plan says the SPECT 
stress test you are requesting does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for patients experiencing new, recurrent, or worsening cardiac symptoms, 
including otherwise unexplained angina equivalent symptoms. 
 
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 SPECT scan. Our reviewer says that a 
SPECT scan is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has had no cardiac symptoms. A radionuclide stress test was performed in 2020 and was normal. Our 
reviewer found there is no documentation that the electrocardiogram shows an uninterpretable pattern or that 
the enrollee is unable to exercise. There is no evidence provided that would support the need for radionuclide 
stress testing at this time. Our physician reviewer also found that there is insufficient documentation to support 
the medical necessity for the requested cardiac stress testing in this enrollees clinical management. 
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single-photon emission computerized tomography (SPECT) scan (78452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower-extremity revascularization (37224, 37226). 
 
You asked the Plan to pre-approve lower-extremity revascularization. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 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 lower-extremity revascularization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has evidence of lower-extremity arterial disease, but the 
documentation is incomplete, with only imaging conclusions that are absent actual patient data. There is no 
evidence that treatment with maximal guideline-directed medical therapy, such as a program of structured 
exercise, and medications such as cilostazol, have been carried out. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower-extremity revascularization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lower-extremity revascularization (37224, 37226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the negative pressure wound therapy (A6550, A7000) 
and bathtub rail (E0242) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the negative pressure wound therapy. You say that you have an infection in 
your left lower leg. You are not getting treatment because you are waiting for the wound pump. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. The Plan approved the wound vac and bathtub rail 
through an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the negative pressure wound therapy (A6550, A7000) and bathtub rail (E0242) to be provided by an out-of-
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple vein procedures (75820, 75822, 37252, 37253, 
76937, 99152, 99153, 75825, 36011, and 36012). 
 
You asked the Plan to pre-approve multiple vein procedures. You say that the request for multiple vein 
procedures is medically necessary. The Plan denied your request. The Plan says the request for multiple vein 
procedures is not medically necessary. 
 
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 multiple vein procedures. Our reviewer 
says that the request for multiple vein procedures is not medically necessary. Our physician reviewer found the 
enrollee is complaining of painful residual varicose veins. There is no documentation of whole leg edema and 
no documentation suggestive of a proximal occlusive process on non-invasive imaging. It is documented that 
the enrollee just had bilateral great saphenous vein (GSV) ablation. There has not been sufficient time to assess 
the enrollees response to these recently performed treatments or if the enrollee is experiencing post procedural 
pain.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multiple vein procedures have not been met. Therefore, we decided that the 
Plan does not have to pre-approve multiple vein procedures (75820, 75822, 37252, 37253, 76937, 99152, 
99153, 75825, 36011, and 36012).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal procedure (22612, 22840). 
 
You asked the Plan to pre-approve the spinal procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the spinal procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found procedures using the Minuteman spinal fixation device are considered investigational. More 
research is needed to show safety and efficacy. 
 
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 spinal procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal procedure (22612, 22840).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair. The Plan denied your request. The Plan says this will 
help the enrollee when grocery shopping and attending doctor visits. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is being requested for use outside of the home. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs medical oversight for their 
medical conditions, and anticoagulation management. You say that the enrollee's needs will not be managed 
well at a lower level of care. You say the enrollee's needs continued physical, occupational, speech and 
neurophysiology services to address their issues with activities of daily living. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary, and the services the enrollee's needs can be 
provided safely in other settings. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 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 are physically and medically necessary 
for the enrollee to return home at their maximum level of functioning with a decreased risk for readmission. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
an inpatient rehabilitation facility. 
 
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. While the enrollee 
continues to have a need for skilled therapy, the care can be received at a lower level. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601), a nasal interface (mask or cannula type) used with positive airway pressure (PAP) device (A7034), 
tubing used with a PAP device (A7037) and a filter, disposable, used with a PAP device (A7038). 
 
You asked the Plan to pre-approve a CPAP device and accessories. You say that the machine you have has not 
been used for 2 months because one of the parts was lost. You travel out of the country often and have asked 
for a replacement device that you can travel with. The Plan denied your request. The Plan says brand-specific 
travel CPAP machines are not covered, and it is not clear why you cannot use the approved functioning CPAP 
machine that you already have. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device (E0601), a nasal interface (mask or 
cannula type) used with positive airway pressure (PAP) device (A7034), tubing used with a PAP device 
(A7037) and a filter, disposable, used with a PAP device (A7038).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve E1028, E2311, E2313, and E2377. We decided that the Plan does 
not have to pre-approve E2300.  
 
You asked the Plan to pre-approve additional power wheelchair accessories (E1028, E2300, E2311, E2313, 
E2377).. You say that this is medically necessary. The Plan says that it is not medically necessary to control the 
three approved power options through the joystick. 
 
We decided that the Plan has to pre-approve E1028, E2311, E2313, and E2377.  
 
The Plan follows Medicare rules. Medicare rules say that services are covered if they are medically necessary. 
 
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 for these items. Our reviewer says that the patient is 
non-ambulatory due to multiple sclerosis and requires a power wheelchair for mobility and performing her 
basic daily activities. The patient cannot perform pressure relief independently due to weakness and spasticity 
and requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. The 
enrollee also requires power elevating leg rests for positioning and her lower extremity spasticity. The 
complexity of the enrollee's seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. The expandable controller with harness and electronic connection are necessary to operate the 
group 3 power wheelchair base and the power tilt and recline and power elevating leg rests via a joystick. The 
manual swing away, retractable, or removable mounting hardware for joystick is required to position the 
joystick and allow the patient to transfer in and out of the power wheelchair. 
 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 services have been met. Therefore, we decided that the Plan has to pre-
approve E1028, E2311, E2313, and E2377.  
 
We also decided that the Plan does not have to pre-approve E2300. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
E2300 does not serve a purpose that is primarily medical in nature. Based on this information, we decided that 
Medicare rules for coverage of E2300 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve E2300. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography, transesophageal, real-time with image 
documentation (2D) (with or without M-mode recording); placement of transesophageal probe only provided to 
the enrollee on August 8, 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 Current Procedural Terminology (CPT) code 93313-59 (1 Unit) remains not supported. 
 
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 code 93313 is "Echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe 
only."  
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 the records do not support 
transesophageal echocardiography (TEE) was performed for diagnostic purposes, and therefore cannot be 
verified. If a TEE is performed by the anesthesiologist for diagnostic purposes, it is billable with a 59 modifier. 
The purpose and outcome must be clearly documented. 
 
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 echocardiography, transesophageal, real-time with image documentation (2D) (with or without 
M-mode recording); placement of transesophageal probe only provided to the enrollee on August 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu (J9358) with Opdivo (J9299). 
 
You asked the Plan to pre-approve Enhertu with Opdivo. You say that there are no good alternatives. The Plan 
denied your request. The Plan says the requested drugs are not approved by the FDA for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Enhertu with Opdivo. Our reviewer 
says that the requested use for Enhertu with Opdivo is not medically necessary. Our physician reviewer found 
the requested use of Enhertu with Opdivo is not approved by the Food and Drug Administration (FDA) for the 
enrollee's condition. The reviewer found that the requested use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer 
found that the requested use of Enhertu with Opdivo is not medically reasonable or 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 Enhertu with Opdivo have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Enhertu (J9358) with Opdivo (J9299).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ForeseeHome device for visual field monitoring 
(0379T x12). 
 
You asked the Plan to pre-approve a ForeseeHome device. You say that the provider believes the ForeseeHome 
device would be best at monitoring the enrollee's current diagnosis. The Plan denied your request. The Plan 
says there is lack of evidence to support ForeseeHome over traditional visual field self-monitoring in the home. 
The Plan also says this type of monitoring has not been proven to be as good or better than standard monitoring 
to detect changes in vision with macular degeneration. 
 
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 a ForeseeHome device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Foresee Home Age Related Macular Degeneration (AMD) monitoring program is 
considered investigational/experimental as additional clinical studies are needed to demonstrate that it affects 
visual outcomes. 
 
 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 ForeseeHome device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ForeseeHome device for visual field monitoring (0379T x12).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says 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 the home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found there is no evidence in the 
record that BiPAP has been tried and failed as an outpatient. Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).