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

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the transcutaneous electrical nerve stimulation (TENS) supplies 
provided on March 15, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that all requested documentation has been 
submitted. The Plan denied your request. The Plan says that a person at the office was asked and indicated that 
the provider did not order the items. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not submitted sufficient information to support its denial based on 
misrepresented services. The Plan's argument stems from a verbal statement from an office representative 
indicating that this device was not ordered. This statement was unacceptably vague and is not considered to be 
valid evidence.  
 
Furthermore, the file as submitted includes a signed standard written order, proof of delivery, and medical 
records which indicate that electrical stimulation in the home was planned. We do not find any deficiency in 
the documentation which would corroborate that the TENS device was provided without being ordered. 
Therefore, we decided that the Plan has to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies provided on March 15, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home blood pressure monitor (A4670). 
 
You asked the Plan to pre-approve the home blood pressure monitor. You say that the home blood pressure 
monitor is medically necessary. The Plan denied your request. The Plan says this device is non-covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor (A4670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature 
(L5848),  an addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), an 
addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature (L5856) 
and an addition, endoskeletal system, above knee, flexible protective outer surface covering system (L5964). 
 
You asked the Plan to pre-approve prosthetics. You say that the components are medically necessary. The Plan 
denied your request. The Plan says the request for K3 microprocessor knee exceeds the enrollee's needs and 
does not meet Medicare criteria as reasonable and 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 prosthetics. 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 K3 microprocessor knee and the specialized prosthetic cover 
at issue in this case meet Medicare criteria for medically reasonable and necessary. Provided records document 
failure of the enrollee's malfunctioning mechanical knee but the records do not document that a new properly 
functioning K3 mechanical knee would not meet the enrollee's needs. The contemporaneous medical records 
from the time of the initial prosthetic request of 05/11/2022 from the enrollee's medical provider do not support 
that the enrollee's environmental exposures are so extreme as to require the requested specialized prosthetic 
cover. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature (L5845), an addition to 
endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848),  an addition, endoskeletal 
system, above knee or hip disarticulation, knee extension assist (L5850), an addition to lower extremity 
prosthesis, endoskeletal knee-shin system, microprocessor control feature (L5856) and an addition, 
endoskeletal system, above knee, flexible protective outer surface covering system (L5964).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
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 an ILR 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 there is no documentation provided to 
suggest a history of syncope or any other apparent indication for an ILR.  In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollee's 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in pain all the time. The 
Plan denied your request. The Plan says this procedure does not improve outcomes compared to standard 
treatment. 
 
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 requested services. Our physician 
reviewer found that the enrollee has low back pain due to a saccrococcygeal disorder. According to the 
literature, sacral lateral nerve branch blocks and ablations for the diagnosis or treatment of sacroiliac joint 
mediated pain is considered experimental. Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational. The review has determined that the 
requested SI joint RFA 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Rush Rogue ankle foot system for the 
enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical documentation that indicates that the member's current mechanical 
K3 level ankle-foot component was damaged or otherwise not properly functioning and in need of replacement 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical documentation does not show that the ankle-foot joint is malfunctioning. There is no 
information regarding lumbar or hip contractures/pathology; thus, L5981 is not 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 the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement Rush Rogue ankle foot system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman Device (33340) and associated inpatient 
hospital admission. 
 
You asked the Plan to pre-approve the Watchman Device and associated inpatient hospital admission. The Plan 
denied your request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CMS covers percutaneous LAAC for NVAF through 
CED with the conditions listed in the Medicare rules section of this letter. 
 
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 Watchman Device and associated 
inpatient hospital admission. Our reviewer says that the requested Watchman Device (33340) and associated 
inpatient hospital admission is not medically necessary or reasonable. Our physician reviewer found the 
enrollee has a A CHADS2 score  2. The enrollee is able to take long-term oral anticoagulation following the 
conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants. 
Our reviewer found that the procedure would be performed by an interventional cardiologist(s), 
electrophysiologist(s), or cardiovascular surgeon(s) that meet the criteria as listed in the NCD. Our physician 
reviewer also found that the enrollee is not enrolled in a prospective, national, audited registry that meets the 
criteria as listed in the NCD. 
 
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 Watchman Device and associated inpatient hospital admission have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Watchman Device (33340) and 
associated inpatient hospital admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for the 
requested services 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 placement of an ILR. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation provided to suggest a history of syncope, cryptogenic stroke or 
any other apparent indication for an ILR. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an ILR.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brand specific scooter. 
 
You asked the Plan to pre-approve a brand specific scooter. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says you were approved a non-brand specific scooter that 
serves the same purpose as the requested brand specific scooter on May 19, 2022. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules also state that for equipment to be covered, it must be appropriate and 
needed for use inside the home. 
 
The file shows that you were approved a non-brand specific scooter. This scooter serves the same purpose as 
the brand specific scooter you are requesting to use outside the home. Therefore, we decided that the Plan does 
not have to pre-approve a brand specific scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they are non-
emergent and can be provided 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 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ophthalmology visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology visit. You say that you were told the requested provider 
is not in your network, but you say the Plans website shows otherwise. The Plan denied your request. The Plan 
says you must use in-network providers to get services when there are network providers available. The Plan 
provided a list of network providers to choose from in your area.   
 
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 
an ophthalmology visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles for a wheelchair (K0108) 
 
You asked the Plan to pre-approve the push handles. You say that the push handles are medically necessary. 
The Plan denied your request. The Plan says these handles are a convenience item and non-covered. 
 
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 push handles for a wheelchair (K0108)
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 requires the level of care provided in an 
IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met in this case. 
The enrollee's care needs can be met in a less intensive setting. 
 
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 documentation does not support that the complexity of the enrollees nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. While the enrollee would benefit from therapy, it is not clear that the enrollee requires at 
least three hours a day for five days a week, or fifteen hours over seven consecutive days of therapy services 
provided in an IRF. The enrollee's needs can be met in a lower 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 17311, 17312) provided to 
the enrollee on November 2, 2021. 
 
You asked the Plan to pay for the services. You say that the related claim has been voided and the services as 
billed are payable. The Plan denied your request. The Plan says this is not reimbursable as a separate charge. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 Mohs surgery by definition and to 
be billed as such is required to have the removal and the pathology performed by one single and same 
surgeon. In this case, two separate providers billed Mohs procedure, and pathology service, and therefore the 
services were incorrectly performed and reported. 
 
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 services (procedure code 17311, 17312) provided to the enrollee on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI (magnetic resonance imaging) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried 6 weeks of physical therapy. 
 
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 the requested MRI is not medically necessary. Our physician reviewer found the submitted 
records do not include details of the enrollee's prior lumbar surgery or any red flags, such as extremity 
weakness or absent reflexes. The necessity of an MRI without a 6-week trial of physical has not been 
established. 
 
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 an MRI (magnetic resonance imaging) of the lumbar spine (72148).