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 enrollee has a diagnosis of chronic 
obstructive pulmonary disease, and hypoxemia. The enrollee requires a unique mode of ventilation with a 
target tidal volume to promote gas exchange due to COPD and hypoxemia. The Plan denied your request. The 
Plan says the request for a home mechanical ventilator set in AVAPS mode with Auto-EPAP (AE) that could 
be delivered by 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As 
stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not 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 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 an expandable controller, harness and electronic 
connector to 2 power options. 
 
You asked the Plan to pre-approve an expandable controller, harness and electronic connector to 2 power 
options. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller, harness and 
electronic connector to 2 power options. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee has adequate upper body strength to manage standard power switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness and electronic connector to 2 power options 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, 
harness and electronic connector to 2 power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual wheelchair repairs coded as K0739 x14, 
E2206 x2, K0077 x2, E2226 x2, E0981, E0982, E2224 x2, E2220 x2, E2205 x2 and K0108 x2. 
 
You asked the Plan to pre-approve the wheelchair repairs.. You say that the records provide support the 
necessity of the requested services in dispute. The Plan denied your request. The Plan says the manual 
wheelchair has exceeded reasonable useful lifetime, and therefore repairing with replacement parts is 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.  
 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 wheelchair repairs. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee uses a light-weight wheelchair supplied in 2016. Per chapter 15 of 
benefit manual section 110.2 as the chair has exceeded its reasonable life expectancy, replacement is 
reasonable and consistent with Medicare rules 
 
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 wheelchair repairs. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the manual wheelchair repairs coded as K0739 x14, E2206 x2, K0077 x2, E2226 
x2, E0981, E0982, E2224 x2, E2220 x2, E2205 x2 and K0108 x2.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 enrollee is chronically deconditioned with an acute decline during a 
modest acute illness. He does not require intensive rehabilitation services. He appears to have had a limited 
response to daily skilled therapy, indicating a limited capacity to respond to intensive therapy.  
 
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 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 an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee has had past pressure 
issues on her buttocks and is at great risk of further pressure issues without the ability to tilt back for pressure 
relief. The power recline is needed to allow for the legs to be elevated to control edema and allow for her hip 
angle to open to control spasticity. Left lower extremity is fused and unable to be situated properly without 
proper positioning. The enrollee has had to be self-catheterization at times as well. All the requested items are 
necessary and needed to prevent further issues and independence. The Plan denied your request. The Plan says 
the enrollee's upper limb strength and function are adequate for the enrollee to be able to 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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of left hemiplegia due to a traumatic brain injury who 
requires a power wheelchair for mobility. Provided records document that the enrollee has 4/5 to 5/5 right 
upper extremity strength and is reported to self-catheterize at times, thus indicating she has adequate upper 
extremity strength and function to operate the wheelchair's power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MTHFR (methylenetetrahydrofolate reductase) genetic 
testing. 
 
You asked the Plan to pre-approve MTHFR gene testing. You say that this test is medically necessary and 
reasonable. The Plan denied your request. The Plan says MTHFR genetic testing is not considered medically 
necessary as it has no clinical utility. 
 
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 MTHFR gene testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found only two germline hereditary mutation tests will be considered medically reasonable 
and necessary when performed for evaluation of venous thromboembolism: Factor II (F2 gene) and Factor V 
(F5 gene). No other gene testing is considered appropriate by Medicare for the evaluation of venous 
thromboembolism. The provided records do not clarify how the result of the test will directly impact your 
treatment. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MTHFR gene testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MTHFR (methylenetetrahydrofolate reductase) genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implantation of wireless pulmonary 
artery pressure sensor for long-term hemodynamic monitoring (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the enrollee needs this device and 
procedure due to his worsening heart failure. The Plan denied your request. The Plan says the CardioMEMS 
device has been determined to be of uncertain value in the most recent 2022 ACC/AHA Guidelines and carries 
a risk of significant complications including death and severe pulmonary artery injury. 
 
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 a CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of 
a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the 
management of enrollees with CHF. The clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was 
implanted, reflecting an enrollee population with preserved ejection fraction and was somewhat limited in 
scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure 
symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is 
supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
enrollee management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollees 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 a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a transcatheter implantation of wireless pulmonary artery pressure sensor for 
long-term hemodynamic monitoring (33289, C2624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for intraoral radiographic images (D0220 and D0230), 
bitewings (D0274), the risk assessment and documentation (D0603), and the application of fluoride (D1208) 
provided by The Wheelchair Store on January 12, 2016."
 
You asked the Plan to pay more for the dental services. You say that you were not notified that you would be 
responsible for payment prior to the treatment that was given. The Plan denied your request. The Plan says 
your annual dental maximum benefit for the year has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. On April 27, 
2022, the Plan paid $126 for dental services. On May 17, 2022, the Plan paid $605 for dental services. On May 
25, 2022, the Plan paid $69 for dental services. On September 7, 2022, the Plan paid $174 for dental services. 
On October 14, 2022, the Plan paid $605 for dental services. On November 29, 2022, the Plan paid $21 for 
dental services. For the year of 2022 the Plan paid $1,600 ($126 paid + $605 paid + $69 paid + $174 paid + 
$605 paid + $21 paid) for dental services; therefore, your annual dental maximum benefit for the year was 
exhausted on the date of service of November 29, 2022. Therefore, we decided that the Plan does not have to 
pay more for intraoral radiographic images (D0220 and D0230), bitewings (D0274), the risk assessment and 
documentation (D0603), and the application of fluoride (D1208) provided by The Wheelchair Store on January 
12, 2016."
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical nerve stimulator provided on October 9, 2022. 
 
You asked the Plan to pay for the device. The Plan denied your request. The Plan says a proof of delivery was 
not submitted. 
 
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 a valid proof of delivery The provided records do not contain a proof of delivery or 
packing slip for items and date of service in question. 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 the electrical nerve stimulator provided on October 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that additional information needed to review this 
claim was not received. The Plan denied your request. The Plan says this claim was filed timely. 
 
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 the laboratory services have been met. 
In this case no medical records were submitted for review. Without this information we are unable to review whether the services provided were medically necessary and meet criteria for coverage. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on May 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the start date for the authorization should be today's 
date, effective March 8, 2023. The Plan denied your request. The Plan says the step therapy requirements have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 Euflexxa have been met. Specifically, 
there was no documentation to indicate whether or not the step therapy criteria have been met. Therefore, we 
decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 15, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery did not include an order number or details to corroborate the delivery ticket submitted, and the proof 
of delivery is not itemized to indicate the specific supplies. 
 
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 argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted, and the proof of delivery is not itemized to indicate the 
specific supplies. However, the records contain an itemized packing slip dated September 15, 2022, with the 
same tracking number as the delivery ticket dated September 20, 2022. As such, the records support that the 
items at issue in this case were delivered. Therefore, we decided that the Plan has to pay for the electrical 
stimulator supplies provided on September 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation shows that home health services discharged patient on March 10, 2023, as stable on home 
exercise program, medically stable on current medications. There has been no documented clinical or 
functional status change since this discharge or order from the provider regarding additional home health 
services. 
 
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 health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies (A4595) provided on October 15, 
2022. 
 You asked the Plan to pay for the electrical stimulator supplies. You say that this claim was billed correctly. 
The Plan denied your request. The Plan says that the documentation does not include a proof of delivery or a 
delivery ticket. 
 
The Plan must follow Medicare rules. Medicare rules say that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
 
We looked at the file and Medicare rules. The record does contain a valid proof of delivery. The electrical 
stimulator supplies are supported by the records provided because the packing slip and the third-party delivery 
tracking information have a tracking number to link those documents together. The documents meet the 
Medicare rules for valid proof of delivery. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulator supplies have been met. Therefore, we decided that the Plan has to pay for 
the electrical stimulator supplies (A4595) provided on October 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical nerve stimulator provided on October 12, 2022. 
 
You asked the Plan to pay for the device. The Plan denied your request. The Plan says the documentation 
submitted did not include a proof of delivery or delivery ticket. 
 
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 a valid proof of delivery for the supplies provided in this case. The submitted 
documentation does not contain a delivery ticket or packing slip for the date of service in question. 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 the electrical nerve stimulator provided on October 12, 2022.