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

 
We decided that the Plan does not have to pre-approve radionuclide stress testing services (78452). 
 
You asked the Plan to pre-approve radionuclide stress testing services. You say that this imaging is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that radionuclide stress testing is subject to the criteria 
listed 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 radionuclide stress testing services. Our 
reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer 
found at issue is the medical necessity of radionuclide stress testing in this patient's evaluation for dyspnea, 
which has been present for some time. He underwent a stress echocardiogram in 2019 which was negative for 
ischemia. Based on the submitted documentation, at this time radionuclide stress testing would not be 
considered medically necessary in this patient'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 radionuclide stress testing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radionuclide stress testing services (78452).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided March 24, 2021 to 
April 5, 2021. 
 
You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Skilled 
Nursing Facility and Swing bed providers must bill the HIPPS codes on the claim form in the order in which 
the beneficiary received that level of care. 
 
We find that these services are not supported in the medical record. Specifically, no HIPPS code was submitted on the claim form. Based on this information, we decided that Medicare rules for coverage of the skilled 
nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for skilled 
nursing facility services provided March 24, 2021 to April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor 5 Leiden (F5) and Factor II Prothrombin (F2) 
genetic testing. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that F5 and F2 testing are non-covered. 
 
We looked at the file and Medicare rules. The services at issue are F5 and F2 genetic testing. This testing is 
non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve Factor 5 Leiden 
(F5) and Factor II Prothrombin (F2) genetic testing.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve home oxygen concentrator and portable oxygen system. 
 
You asked the Plan to pre-approve home oxygen concentrator and portable oxygen system. You say that this 
equipment is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mm Hg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 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 home oxygen concentrator and portable 
oxygen system. Our reviewer says that the requested home oxygen concentrator and portable oxygen system 
are medically reasonable and necessary. Our physician reviewer found a home oxygen concentrator and 
portable oxygen system are medically necessary. The most recent visit from January 20, 2022, describes SpO2 
falling to 88% on walking, and breathing.  A previous visit from January 24, 2020, showed SpO2 decreasing to 
86% with walking, increasing to 95% "on O2". The flow rate is not described, but other records indicate that 
you have always used 2 L/min, as prescribed.  The combination of these data meets Medicare coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home oxygen concentrator and portable oxygen system have been met. 
Therefore, we decided that the Plan has to pre-approve home oxygen concentrator and portable oxygen system.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodontal maintenance (D4910) to be rendered by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the periodontal maintenance. You say that the Plan wants you to go to a 
dentist in another state and you do not feel comfortable going to another state to receive the services. The Plan 
denied your request. The Plan says this service is only allowed to be done by a dentist that accepts your plan, 
and the provider that requested this service does not accept your plan. The Plan also says that there are in-
network providers available to complete the requested services who are within your current home state. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a 
periodontal maintenance (D4910) to be rendered by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent (64633 and 64634). 
 
You asked the Plan to pre-approve the destruction by neurolytic agent (64633 and 64634). You say that the 
doctors believe the procedure for pain reducing injections in your back are medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show you do 
not have two diagnostic medial branch blocks yielding 80% or better improvement in your pain. 
 
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 destruction by neurolytic agent 
(64633 and 64634). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the records do not show that there 
were two diagnostic medial branch blocks yielding 80% or better improvement in your pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the destruction by neurolytic agent (64633 and 64634) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the destruction by neurolytic agent (64633 
and 64634).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurostimulator implantation (63650). 
 
You asked the Plan to pre-approve the neurostimulator implantation (63650). You say that significant clinical 
literature supports the safety and efficacy of this procedure which is medically indicated and appropriate for 
this patient. You say that this is the best clinical option given the patient's medical history and treatment 
options. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the neurostimulator implantation 
(63650). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding trial 
and failure of recent, reasonable, and comprehensive less invasive conservative care measures. There are no 
formal imaging studies of the lumbar spine provided for review that show pathology of the lumbar spine that 
would not be able to be treated with other measures. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 neurostimulator implantation (63650) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the neurostimulator implantation (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) 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 this 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 a power seat elevation system (E2300) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the needs for mobility and positioning may be met with a lesser device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the patient meets Medicare criteria for the various 
accessories. The records from the enrollee's medical provider do not document the need for bladder 
catheterization and an inability to independently transfer or the presence of spasticity to support the power tilt 
and recline. The power seat elevation and push handles are not covered as they do not serve a medical purpose; 
the upgraded electronics are not covered as records do not document the enrollee's upper extremity strength is 
inadequate to control the power options with their own switches. A group 3 power wheelchair without these 
various accessories appears indicated in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 standard power wheelchair with multiple power options for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like for Medicare 
to cover the limb compression device. The Plan denied your request. The Plan says items that are used for a 
preventative service or function are excluded from coverage under the Medicare DME benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found while you may benefit from skilled therapy 
services, the documentation does not support that it is medically reasonable and necessary to provide skilled 
therapy services on a daily basis on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. The 
enrollee's rehab needs can be met safely at a lower intensity and alternate setting such as in a skilled nursing 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says you are not bed bound and have a supportive spouse. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found although the available 
records document Parkinson's disease with progressive weakness, the records do not state that your condition 
requires positioning of the body in ways not feasible in an ordinary bed, or frequent changes in body position, 
or the need for immediate changes in body position. The records do not state that your condition requires 
special attachments that cannot be fixed and used on an ordinary bed. The records do not support that you meet 
Medicare criteria for a semi-electric hospital bed as defined by the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, 
Section 280.7(D). 
 
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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found while you may benefit from skilled therapy 
services, the documentation does not support that you require skilled therapy services on a daily basis on an 
inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the repeat ESI. You say that it is felt that another injection would help to 
continue the enrollee's pain relief. The Plan denied your request. The Plan says prior injections have not 
provided sustained pain relief nor objective improvements in function. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs may be covered when prior injections 
provided at least 50% pain relief for at least 3 months and contributed to improvements in function. 
 
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 repeat ESI. Our reviewer says that 
the criteria for a repeat ESI are not met in this case. Our physician reviewer found the enrollee's first ESI was 
completed at right L3, L4; however, he received minimal relief at those levels x1 day. The enrollee had his 2nd 
transforaminal lumbar epidural steroid injection at right L2, L3 (11/1/2021). The patient received 50% relief 
from the second injection, lasting 1-2 months. He still has some improvement; however, his pain has started to 
return to baseline. The doctor's notes did not document if easier for the enrollee to do specific activities. Based 
on this information, the Medicare criteria for a repeat ESI are not met. 
 
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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).