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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is 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 a home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee may benefit from BiPAP with average volume assured pressure support (AVAPS) during sleep 
as an outpatient. However, Medicare does not cover a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, single power 
option, captain's chair, patient weight capacity up to and including 300 pounds (K0836) and accessories 
(E0955, E1002, E1028, E2361, E2603). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says the enrollee has 
difficulty in standing and walking, however the note does not show that he is at high risk for pressure ulcer and 
is unable to perform a functional weight shift. The request for the power tilt is not supported. A lesser power 
mobility device will meet the enrollees need for mobility. The requested power wheelchair is not reasonable or 
necessary at this time. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the 
medical records provided there is documentation that this enrollee has a personal mobility deficit that impairs 
participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in 
customary locations within the home. There is documentation that the enrollee's mobility deficit cannot be 
helped by the use of a walker, cane or manual wheelchair due to his level of weakness and instability. Provided 
records do not support that the enrollee is high risk for skin breakdown (provided records document he uses a 
walker at times for mobility), has a history of pressure ulcer(s) or has had skin flap surgery. Records do not 
document he performs bladder self-catheterization and is unable to transfer independently or that the power tilt 
is needed to manage increased muscle tone or spasticity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 2 standard, single power option, captain's 
chair, patient weight capacity up to and including 300 pounds (K0836) and accessories (E0955, E1002, E1028, 
E2361, E2603).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom-fabricated seat cushion (E2609, E2617). 
 
You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are other types of pre-made cushions that have yet been tried. 
 
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 cushion. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that the 11/20/22 therapist evaluation states that a pre-fabricated cushion is required to prevent skin breakdown. 
Your kyphosis and postural asymmetry can be accommodated with prefabricated cushions. 
 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 cushion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom-fabricated seat cushion (E2609, E2617).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ESI (CPT code 62323). 
 
You asked the Plan to pre-approve the ESI. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been 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 the ESI. Our physician reviewer found 
the enrollee experienced pain relief only for a few days after the transforaminal ESI (TFESI) on December 
2022. There is no documentation that new levels or a new approach would be used. 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ESI (CPT code 62323).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for emergency air ambulance (A0430 and A0435) provided on February 2, 
2022. 
 
You asked the Plan to pay for the services. You say that this was an emergency transport, and the flight was not 
pre-scheduled. The Plan denied your request. The Plan says that the documentation submitted does not support 
the use of a fixed wing aircraft. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for the services. Our physician reviewer found 
given the nature of the enrollees illness and the distance between facilities, the use of an air ambulance to 
transport the patient was medically necessary and reasonable. The enrollees condition was emergent. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
emergency air ambulance (A0430 and A0435) provided on February 2, 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: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 levels of RFA. We decided that the Plan does not have to pre-
approve 3 levels of RFA.  
 
You asked the Plan to pre-approve 5 levels of radiofrequency ablation (RFA). You say that the services are 
necessary. The Plan says that based on the documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve 2 levels of RFA.  
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 2 levels of RFA. Our reviewer says that 
the services are medically necessary Our physician reviewer found the LCD utilization criteria is limited to 2 
levels of RFA at a session. Only 2 levels are deemed medically reasonable and 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 2 levels of RFA have been met. Therefore, we decided that the Plan has to pre-
approve 2 levels of RFA.  
 
We also decided that the Plan does not have to pre-approve 3 levels of RFA. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 3 levels of RFA. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the LCD utilization criteria is limited to 
2 levels of RFA at a session. Only 2 levels are deemed medically reasonable and 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 3 levels of RFA have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 3 levels of RFA. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you do meet the IRF admission criteria, and your 
ongoing rehabilitative needs warrant an IRF level of care. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information about your condition, you do not meet all the requirements for an 
IRF admission. 
 
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 you are currently at home and your medical conditions are stable enough to be managed with home health nursing or on an outpatient basis. You do not require the intensity of rehabilitation 
physician oversight provided in an IRF. Your medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided at an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for patients that 
do not receive adequate relief from traditional conservative methods and do not have instability to indicate that 
fusion is appropriate. The Plan denied your request. The Plan says studies have not proven this service is 
helpful for the treatment of the enrollee's condition. 
 
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 Intracept. 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 Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee brace (L1851) and sleeve (L2397), provided on 
August 26, 2022. 
 You asked the Plan to pay for a knee brace and sleeve. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the request is not medically necessary because the records do not 
support the need or justification for the brace. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records submitted in the file dont include any information on the clinical course, prognosis, 
functional limitations, or other interventions.  The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
knee brace (L1851) and sleeve (L2397), provided on August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex medical 
management situations that require LTACH care. The Plan denied your request. The Plan says the LTACH 
admission you requested does not meet Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but not yet stable and should only require short-
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and completion of treatment at the current facility is recommended. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power scooter and stair lift provided on April 6, 2021. 
 
You asked the Plan to pay for the power scooter and stair lift. You say that the items were medically necessary. 
The Plan denied your request. The Plan says these are not covered items. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the power scooter and stair lift have 
been met. There were no medical records submitted in this case to review medical necessity. Therefore, we 
decided that the Plan does not have to pay for the power scooter and stair lift provided on April 6, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve power wheelchair, group 3 very heavy duty, single power option, 
sling/solid seat/back, patient weight capacity 451 to 600 pounds (CPT code K0860) and the requested 
accessories (E0951, E0955, E1002, E1010, E1028, E2311, E2313, E2363, E2377, E2608, E2621, K0108). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says that the DME is not 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 the DME. Our physician reviewer 
found given the enrollee's short stature and history of Blounts disease the enrollee requires power elevating leg 
rests for appropriate positioning of lower extremities. A group 3 power wheelchair would still be more 
appropriate than a group 2 wheelchair given the enrollee's complex seating needs from Blounts disease and the 
enrollee's size. The enrollee has been evaluated by a physical therapist and can operate the power wheelchair. 
Therefore, the group 3 power wheelchair with power tilt and power elevating leg rests is 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 DME have been met. Therefore, we decided that the Plan has to pre-approve 
power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 
451 to 600 pounds (CPT code K0860) and the requested accessories (E0951, E0955, E1002, E1010, E1028, 
E2311, E2313, E2363, E2377, E2608, E2621, K0108).   
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (80299, 80307, 83789, G0481) 
provided on August 9, 2022. 
 
You asked the Plan to pay for drug testing services. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says there is insufficient 
documentation to support the medical necessity of these services. In addition, the place of service code is 
inconsistent based on the documentation provided and code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing services have been met. 
Specifically, the records provided do not contain any physician notes to support medical necessity and indicate 
intent for these tests to be performed. Therefore, we decided that the Plan does not have to pay for drug testing 
services (80299, 80307, 83789, G0481) provided on August 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-Factor allograft. 
 
You asked the Plan to pre-approve i-Factor allograft. 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 i-Factor allograft. 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 compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested i-Factor allograft, in this 
case, 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 i-Factor allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve i-Factor allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 2 therapeutic CGM sensor (K0553). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules 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 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 enrollee does not show that the enrollee takes multiple insulin 
injections per day and that the enrollee is on an insulin pump. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the FreeStyle Libre 2 therapeutic CGM sensor (K0553).