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

 
We decided that the Plan does not have to pre-approve the high frequency chest wall oscillation system 
(E0483). 
 
You asked the Plan to pre-approve the high frequency chest wall oscillation system. You say that you are 
requesting a review of the denial of coverage for the Vest system, which was prescribed to help manage the 
enrollee's ongoing respiratory needs at home. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve the high frequency chest wall oscillation system (E0483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a massage chair (E1399). 
 
You asked the Plan to pre-approve a massage chair. You say that the enrollee needs a massage chair due to 
knee pain. The Plan denied your request. The Plan says massage devices are considered personal comfort 
items. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a massage chair (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 fractions of stereotactic body radiotherapy (SBRT). 
 
You asked the Plan to pre-approve 8 fractions of SBRT. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 8 fractions of SBRT. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found SBRT has defined by ASTRO, and therefore by insurers, to apply only to those 
treatments delivered in 5 or fewer fractions. When SBRT techniques are used for the treatment of 6 or more 
fractions, either intensity-modulated radiation therapy (IMRT) (if planned with IMRT) or 3D dynamic 
conformal arc (3D-DCA) therapy are billed. The treatment is appropriate and standard of care, the billing of 
this should be 8 fractions of IMRT of 3D-DCA (no plan is provided so it is not known how this enrollee was 
planned). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 fractions of SBRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 fractions of stereotactic body radiotherapy (SBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit by the Plan or by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
documentation of the degree or duration of pain relief from these prior injections. There is no documentation of 
active home exercise or physical therapy. Therefore, at this point, the request is deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve battery backup for continuous positive airway pressure 
(CPAP). 
 
You asked the Plan to pre-approve battery backup for CPAP. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested device is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve battery backup for continuous positive airway pressure 
(CPAP).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Timolol Mal solution. 
 
You asked the Plan to pre-approve Timolol Mal solution. The Plan denied your request. The Plan says Timolol 
is a self-administered drug, and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Timolol Mal solution.  
 
  Benefits for Timolol Mal solution may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional features for a leg prosthetic (L5850, L5845, 
L5981, L5986, L5988). 
 
You asked the Plan to pre-approve the features. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes from the physician do not show K3 level ambulation. 
 
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 features. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested advanced knee and advanced ankle exceeds the enrollee's needs. The patient is using 
an assistive device and does not appear to be a K3 ambulator. The documentation does not support that the 
patient is participating in high impact activity therefore the shock reducing pylon exceeds the patient's 
functional needs. 
 
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 features have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional features for a leg prosthetic (L5850, L5845, L5981, L5986, L5988).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emerging Solutions peripheral nerve stimulator implant 
Opirelief device (64555). 
 
You asked the Plan to pre-approve the peripheral nerve stimulator implant. You say that the enrollee has tried 
and failed conservative care and medication therapies. The Plan denied your request. The Plan says this type of 
electrical stimulator is not evidence-based and is not scientifically proven by peer-reviewed published 
mainstream medical literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of peripheral nerve stimulator implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Emerging Solutions peripheral nerve stimulator implant Opirelief device (64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of blepharoptosis. 
 
You asked the Plan to pre-approve repair of blepharoptosis. 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 follows Medicare rules. Medicare rules say that upper blepharoplasty (removal of upper eyelid skin) 
and/or repair of blepharoptosis (drooping of the upper eyelid, which relates to the position of the eyelid margin 
with respect to the eyeball and visual axis) is considered functional in nature when the upper lid position or 
overhanging skin (see pseudoptosis below) is sufficiently low to produce a functional deficit related to visual 
field impairment or brow fatigue. 
 
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 repair of blepharoptosis. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there are no photographs 
provided to document the relationship of the eyelid margin with the visual axis to support the medical necessity 
of the requested ptosis repair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repair of blepharoptosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repair of blepharoptosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network dialysis center. 
 
You asked the Plan to pre-approve these services. You say that you have had negative experiences with the 
network facility. The Plan denied your request. The Plan says the services are available from network 
providers. 
 
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. The Plan confirmed that they have network 
providers outside of the facilities you previously have seen. 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 a referral 
to an out-of-network dialysis center.
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 enrollee currently meets IRF admission criteria, 
and their ongoing rehabilitative needs warrant an IRF level of care. The Plan denied your request. The Plan 
says the enrollee does not meet the Medicare criteria for an admission to an IRF. 
 
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 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. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and 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. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. The Plan denied your request. The Plan says 
this request cannot be approved because the records do not show results of a face-to-face workup (evaluation) 
that support the requested study. The Plan also says that a detailed history was not received showing the study 
is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when 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 to pre-approve an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not reasonable or necessary. Our physician reviewer found the 
notes state that physical therapy has been done, but there are no notes or details concerning such therapy. The 
medical necessity for the requested MRI is not documented in the records nor the additional information 
supplied. Our reviewer also found that without documentation for physical therapy, the medical necessity of the 
requested exam is not yet established in the materials submitted. 
 
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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided by an out-of-network 
provider on May 23, 2022. 
 
You asked the Plan to pay for an occlusal guard. You say that you need this night guard to protect your teeth. 
The Plan denied your request. The Plan says the rendered dental product is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
occlusal guard (D9944) provided by an out-of-network provider on May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing: PancNext (81479). 
 
You asked the Plan to pre-approve the genetic testing. You say that the test was ordered because of the type of 
pancreatic cancer that you have and it's a matter of routine testing. The Plan denied your request. The Plan says 
the enrollee does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. The records show that the Plan has already approved Omniseq, NGS 
testing which was completed on August 30, 2022. Based on this information, we decided that Medicare rules 
for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve genetic testing: PancNext (81479).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on March 19, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microprocessor knee and foot features for an approved 
Prosthetic (L5828, L5845, L5848, L5856, L5973). 
 
You asked the Plan to pre-approve the microprocessor knee and foot features. You say that these features are 
medically necessary. The Plan denied your request. The Plan says the microprocessor features exceed the 
enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for prosthetic features is extended only if 
there is sufficient clinical documentation of functional need for the technologic or design features. 
 
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 microprocessor knee and foot 
features. Our reviewer says that the requested features are not medically necessary. Our physician reviewer 
found there is no documentation showing the enrollee is unable to use a standard mechanical K3 knee and foot. 
 
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 microprocessor knee and foot features have not been met. Therefore, we 
decided that the Plan does not have to pre-approve microprocessor knee and foot features for an approved 
Prosthetic (L5828, L5845, L5848, L5856, L5973).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0296). 
 
You asked the Plan to pre-approve a hospital bed. You say that your doctor has prescribed an adjustable bed to 
alleviate acid reflex from Gerd. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0296).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator (Bioness L300 Go). 
 
You asked the Plan to pre-approve a functional electrical stimulator (Bioness L300 Go). 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 follows Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is limited 
to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy. 
 
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 functional electrical stimulator 
(Bioness L300 Go). Our reviewer says that the services are not medically necessary. Our physician reviewer 
found provided records do not document this enrollee has a history of a spinal cord injury. 
 
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 functional electrical stimulator (Bioness L300 Go) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator (Bioness 
L300 Go).