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

 
We decided that the Plan does not have to pre-approve the continuous passive motion exercise device for use 
on knee only (E0935). 
 
You asked the Plan to pre-approve the continuous passive motion exercise device. You say that the referral is 
stating that the Plan is denying 56-day coverage by saying you can only keep this for 21 days and you want to 
appeal this. The Plan denied your request. The Plan says continuous passive motion devices are limited to a 21-
day period following surgery. The 21 days was approved by the Plan and the additional 35 days is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that coverage for CPM devices is limited to the three-week 
period following total knee replacement surgery during which the device is used in the home. 
 
Records show that knee replacement surgery was received on October 18, 2022. The file shows that a CPM 
device was used for three weeks following this surgery. Therefore, we decided that the Plan does not have to 
pre-approve the continuous passive motion exercise device for use on knee only (E0935).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with auto-expiratory positive airway pressure (EPAP) (AE) that could be 
delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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 physician 
reviewer found the provided primary source documentation does not contain sufficient detailed information in 
the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
AVAPS capability. The Plan has indicated coverage for such a device is available upon request. The elements 
of the coverage criteria are not satisfied. 
 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 the home ventilator (CPT code E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homemaker services/personal care services (T1019). 
 
You asked the Plan to pre-approve the services. You say that you need to have someone there to help you get to 
the bathroom, so you do not fall. You state you need help making meals and putting clothes on. The Plan 
denied your request. The Plan says you are requesting personal care/homemaker services in your home. The 
Plan states as Medicare does not cover personal care or homemaker services, this request for coverage has been 
denied. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve homemaker 
services/personal care services (T1019).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin substitute (Grafix PRIME, GrafixPL PRIME, 
Stravix and StravixPL, per sq cm) (CPT code Q4133). 
 
You asked the Plan to pre-approve the skin substitute. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the request for use of a skin substitute is not medically necessary 
because the documentation does not support that adequate circulation to support wound healing has been 
established. 
 
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 skin substitute. Our physician 
reviewer found there is no indication that the vascular status of this limb has been further addressed in the 
submitted documentation. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
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 skin substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a skin substitute (Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm) 
(CPT code Q4133).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you say that you would like a power 
wheelchair to replace the power scooter for use in your home and would like to keep the power scooter for use 
outside the home. The Plan denied your request. The Plan says you received an approved power scooter in 
December 2019. 
 
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 file shows that you have power scooter. A power scooter serves the same purpose as a power wheelchair. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic, prophylactic, or diagnostic injection provided to 
the enrollee on August 20, 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 place of service is inappropriate. 
 
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 find that CPT code 96372 is not supported in the medical record. Specifically, this code has a Professional 
Component/Technical Component Indicator of "5" which means that it is not appropriate to furnish to hospital 
outpatients. This was billed with Place of Service (POS) 23 for on campus outpatient hospital. 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 therapeutic, prophylactic, or diagnostic injection provided to the 
enrollee on August 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553). 
 
You asked the Plan to pre-approve the CGM device and supplies. You say that you will be starting insulin soon 
and the doctor has ordered you a glucose monitor to check your levels daily. The Plan denied your request. The 
Plan says the enrollee is not taking insulin injections and does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM device and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has age-related 
osteoporosis without osteoporotic fracture. She has not tried and failed the Plan's required drug, Forteo. The 
records do not show that the required drug would be contraindicated or less effective; therefore, Evenity is 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 Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy. 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. 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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found certainly using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. The device itself is FDA approved for use with ultrasound though that in and of itself does 
not mean that daily imaging is necessary but simply that the device was designed to incorporate this 
functionality. Therefore, to bill for daily simple simulations and/or image-guided radiation therapy (IGRT) for 
a technology for which need has not been established by published data or supported by consensus guidelines is 
not necessary. Billing for daily IGRT which would not be furnished in accordance with accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy.
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 will receive the appropriate level of care 
in the IRF setting and further delay in care will have a detrimental effect on the enrollee's safety, ability to fully 
recover, and be discharged to a community setting, averting unplanned readmissions. The Plan denied your 
request. The Plan says the 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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they would meet criteria for admission to an 
acute inpatient rehabilitation facility. The enrollee can receive further services at 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 IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the unlisted molecular pathology procedure (81479) provided June 14, 
2021. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's doctor ordered the AlloSure test as 
a safe and effective method to aid in evaluating the probability of organ rejection for the enrollee. The Plan 
denied your request. The Plan says that the point of service benefit has been exhausted. 
 
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 substantiated their reason to continue to deny the claim. In this 
case, the Plan stated that $5,000 out of network, point of service benefit was exhausted. The Plan did not 
provide any information showing the dates of service and amounts to show that show the $5,000 benefit had 
been paid. The Plan has not provided records to show that the benefit has been exhausted. The Plan also did not 
provide the correct Evidence of Coverage in the case file that indicates that there is a $5,000 limit to the Point 
of Service benefit. Therefore, we decided that the Plan has to pay for the unlisted molecular pathology 
procedure (81479) provided June 14, 2021.  
 
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 ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure from chronic obstructive pulmonary disease (COPD). He was successfully treated with bi-level positive 
airway pressure (BiPAP) therapy. The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The home ventilator is 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 home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with auto-expiratory positive airway pressure (EPAP) (AE) that could be 
delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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 physician 
reviewer found the record indicates that the enrollee was successfully treated with BiPAP. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The Plan 
has indicated coverage for such a device is available upon request. The elements of the coverage criteria are not 
satisfied.  
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 the home ventilator (CPT code E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in 
the setting of vertebrogenic back pain have not been demonstrated in the peer-reviewed literature. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (64628 and 64629).