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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0656, E0652, 
E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0656, E0652, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) services provided on 
July 21, 2021. 
 
You asked the Plan to pay for moderate sedation services (99153). The Plan denied your request. The Plan says 
CPT code 99152 is supported by the medical records submitted. The Plan also says CPT code 99153 may not 
be paid if furnished to hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) services 
provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. You say that radiofrequency ablation 
to the SI joint is medically necessary. The Plan denied your request. The Plan says radiofrequency ablation to 
the SI joint 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 radiofrequency ablation to the SI joint. 
Our reviewer says that radiofrequency ablation to the SI joint is not considered medically reasonable and 
necessary. Our physician reviewer found this is considered an experimental/ investigational procedure because 
of the wide variation in efficacy as reported in the literature.   
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader device. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 reader device. You say that the reader is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet prior authorization 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 use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 reader device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 reader device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy including use of a transcutaneous 
electrical nerve stimulator (TENS) unit. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee needs aggressive therapy to 
improve their outcome. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for the requested use of a TENS unit.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found because the requested use of a TENS unit is unattended and therefore 
not requiring the skill of a professional therapist, it is medically unnecessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy including use of a transcutaneous electrical nerve stimulator (TENS) 
unit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of a skin substitute graft to trunk, arms, legs 
(15271). 
 
You asked the Plan to pre-approve EpiFix allograft. You say that the medical records provided support the 
necessity of the requested services. The Plan denied your request. The Plan says per the Plan's policy, the 
requested treatment is considered investigational for the diagnosis given and is therefore not reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
 
 
 
 
 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of EpiFix allograft have not been met. Therefore, we decided that the Plan does not have to pre-
approve application of a skin substitute graft to trunk, arms, legs (15271).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve four physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee is benefiting from therapy services. 
The Plan denied your request. The Plan says that the enrollee appears to have plateaued in the ability to 
progress with skilled therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve therapy visits. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that the clinical documentation shows that the 
enrollee is a high fall risk with balance impairments. In this case, the four additional physical therapy sessions 
are 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 therapy visits have been met. Therefore, we decided that the Plan has to pre-
approve four physical therapy visits.  
 
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 the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by her nurse 
practitioner for myoelectric orthotic restoration using the MyoPro Motion G. The Plan denied your request. The 
Plan says this item is considered experimental and investigational and not covered by Original Medicare. There 
is insufficient evidence of its safety and/or efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for thrombophilia (81240, 81241). 
 You asked the Plan to pre-approve genetic testing. You say that the enrollee is showing symptoms of 
thrombophilia, and this testing is medically necessary and reasonable. The Plan denied your request. The Plan 
says these services are not medically necessary and reasonable according to Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for inherited thrombophilias is 
indicated for pregnant women with a previous history of VTE associated with a transient risk factor when this 
genetic testing would impact treatment. There is insufficient evidence in published peer-reviewed scientific 
literature to support coverage for this testing outside of pregnant women as described. This testing is 
considered investigational for all other indications.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the enrollee does not fall into the category of 
people for whom this testing is indicated. Therefore, we decided that the Plan does not have to pre-approve 
genetic testing for thrombophilia (81240, 81241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backpack holder and light-emitting diode (LED) light 
package for a power wheelchair. 
 
You asked the Plan to pre-approve backpack holder and LED lights. You say that the enrollee has problems 
and has experienced falls. The Plan denied your request. The Plan says the denial of authorization for these 
components is correct, because these components are not primarily medical in nature. 
 
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 backpack holder and light-emitting diode (LED) light 
package for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric seat lift with chair. 
 
You asked the Plan to pre-approve an electric seat lift with chair. You say that this chair is medically necessary 
due to Parkinson's. The Plan denied your request. The Plan says the Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. Based on the records provided, you are capable of getting up from 
a chair. Medicare rules for coverage of the requested chair not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electric seat lift with chair.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 8 additional occupational therapy visits. 
 
You asked the Plan to pre-approve occupational therapy. You say that you are appealing this denial. The Plan 
denied your request. The Plan says that the requested 8 additional occupational therapy visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve occupational therapy. Our reviewer 
says that you meet the Medicare criteria for the requested occupational therapy. Our physician reviewer found 
clinical documentation shows that you have cervical myelopathy with weakness and require maximum 
assistance with functional tasks. Additional occupational therapy is medically necessary due to the severity of 
your functional impairment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occupational therapy have been met. Therefore, we decided that the Plan has to 
pre-approve 8 additional occupational therapy visits.  
 
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 electronic connection between wheelchair controller and 
two or more power seating system motors, including all related electronics, indicator feature, mechanical 
function selection switch, and fixed mounting hardware (E2311). 
 
You asked the Plan to pre-approve the upgraded electronic. You say that please review the attached 
documentation for further justification in providing this enrollee with the equipment needed to complete his 
mobility related activities of daily living. The Plan denied your request. The Plan says the requested E2311 
exceeds the enrollee's need as the enrollee can control the power options using their own switches which are 
included in the allowance of these power options. 
 
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 upgraded electronic. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the expandable controller is not medically necessary as the enrollee has function in 
his left hand.  He does not require the additional features for alternate wheelchair control methods. The request 
exceeds what is necessary to meet his care 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 upgraded electronic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors, including all related electronics, indicator feature, mechanical function selection switch, 
and fixed mounting hardware (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom CGM. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrolysis of a facial skin flap. 
 
You asked the Plan to pre-approve electrolysis of a facial skin flap. You say that electrolysis of a facial skin 
flap is medically necessary. The Plan denied your request. The Plan says electrolysis of a facial skin flap 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 electrolysis of a facial skin flap. Our 
reviewer says that electrolysis of a facial skin flap is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the provided records do not document that the procedure will treat an 
illness or injury or improve the functioning of a malformed body member as required by Medicare rules. The 
provided records do not document that the procedure is for anything other than cosmetic purposes.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electrolysis of a facial skin flap have not been met. Therefore, we decided that 
the Plan does not have to pre-approve electrolysis of a facial skin flap.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for immunoglobulin light chains lab testing (83521) provided on April 4, 
2022. 
 
You asked the Plan to pay for immunoglobulin light chains testing. You say that you have had these testing 
services provided since January of 2019, and they had always been covered. The Plan denied your request. The 
Plan says that the requested service is considered investigational/experimentational, and previously these 
services were billed with code 83520. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for immunoglobulin light chains testing by a contract provider. The file does not show that 
the Plan provided notice that immunoglobulin light chains testing would not be covered, and the documentation 
does not show that the provider informed you that this service would be billed differently and no longer 
covered. Under Medicare rules, this means immunoglobulin light chains testing is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for immunoglobulin light chains lab testing (83521) 
provided on April 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS) treatment. 
 
You asked the Plan to pre-approve TMS treatment. You say that TMS treatment is medically necessary. The 
Plan denied your request. The Plan says TMS treatment does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 TMS treatment. Our reviewer says that 
TMS treatment is not medically necessary. Our physician reviewer found based on the information provided, 
this enrollee does not meet the clinical criteria for the use of TMS therapy utilizing LCD (L34522) as the 
enrollee is diagnosed with bipolar disorder, which is not considered a disease that warrants the use of TMS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TMS treatment.