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

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the ventilator is medically necessary. 
Without NIV therapy, the enrollee is at high risk for hospital readmission and potentially life-threatening 
exacerbations. 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has very severe COPD. 
A recent arterial blood gas showed mild CO2 retention. This enrollee may benefit from BiPAP with AVAPS 
during sleep as an outpatient. This has not been tried and failed as an outpatient. Medicare does not cover a 
home ventilator when used at settings that can be provided with 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is legally blind and has a bilateral lower 
extremity amputation. You say that the enrollee will not get the level of care they need in another setting. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs 
can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional supplements. 
 
You asked the Plan to pre-approve nutritional supplements. You say that you cannot chew. The Plan denied 
your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve nutritional supplements.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve an occlusal guard. You say that you are grinding your teeth. The Plan 
denied your request. The Plan says the requested mouth guard is not a covered benefit. 
 
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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (D9944).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the contrast material provided on November 22, 
2022. We also decided that the Plan does not have to waive the copayment for the CT scan provided on 
November 22, 2022.  
 You asked the Plan to waive the cost share for the CT scan and contrast material. You say that you received a 
letter stating your cost sharing would be $55. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the contrast material provided on November 
22, 2022.  
 
The contrast material (code Q9966) is considered a packaged code and not separately payable. Code Q9966 is 
also excluded from the physician fee schedule. Therefore, we decided that the Plan has to waive the 
coinsurance for the contrast material.  
 
We also decided that the Plan does not have to waive the copayment for the CT scan provided on 
November 22, 2022. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each Medicare covered diagnostic imaging service, including CT scans.  
 
You have been asked to pay a $300 copayment for the CT scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the CT scan provided on November 22, 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 pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you had the ventilator for a very long time, 
and you need this device daily. The Plan denied your request. The Plan says a home ventilator was prescribed 
to be used exclusively in a VAPS setting, which is a BiPap mode. Records do not show that you have failed 
management with BiPap, and the ventilator prescription indicates the device will be used exclusively in a 
BiPap setting. Under Medicare, 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 service is not medically necessary. Our physician reviewer found you have apparently had a home 
ventilator since 2017. At that time, you suffered a cardiopulmonary arrest and was hospitalized with 
pneumonia. You were mechanically ventilated, underwent tracheostomy, and facility rehabilitation. There are 
notes describing subsequent hospitalizations with hypercarbic respiratory failure. There is one arterial blood 
gas result from January 27, 2023, that shows a normal pH and increased PCO2. Your circumstances at that time 
are not provided. You are a non-smoker and have a diagnosis of asthma, COPD, and HFpEF. There is a 
suspected diagnosis of obstructive sleep apnea.  Clinical notes indicate you have not been using the home 
ventilator.  There is no device download to assess compliance. It appears that your ventilatory support needs 
could be met with BiPAP with AVAPS during sleep. There is no evidence this has been tried and shown to fail. 
Medicare does not cover a home ventilator when used at settings that can be provided with 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on October 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the code billed. 
 
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 G0483 is drug testing, definitive, 22 or more classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show 
testing for 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(G0483) provided on October 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous device placement (22869). 
 
You asked the Plan to pre-approve the interspinous device placement. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the Vertiflex device is experimental and non-covered. 
 
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 interspinous device placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the records did not include recent imaging studies to support the requested 
service. 
 
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 interspinous device placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous device placement (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TomoTherapy System with 3D-conformal radiation 
therapy (77387, 77412, G6002 and G6014). 
 
You asked the Plan to pre-approve the radiation therapy. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of the TomoTherapy System with 
3D-conformal radiation therapy in the setting of palliative radiation therapy for extensive metastatic non-small 
cell lung cancer (NSCLC) have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found image-guided radiation therapy (IGRT) is not an accepted standard of care for routine 
use in the palliative treatment of bone metastases or whole brain radiotherapy. Standard of care would be two-
dimensional radiotherapy (2DRT) with portal imaging (or for the case of this commercial vendor, one could 
bill a simple simulation prior to treatment in lieu of portal imaging or IGRT). 
 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 radiation therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the TomoTherapy System with 3D-conformal radiation therapy (77387, 77412, 
G6002 and G6014).
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 was admitted for peripheral vascular disease and had an above the knee 
amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has suffered for more than two (2) 
years from mid-line of low lumbar area, sitting intolerance with an average reported pain level of 8 out of 10 on 
a numeric/visual analog scale. The Plan denied your request. The Plan says your request is not medically 
necessary because there is little evidence in the medical literature to suggest that this is an appropriate 
procedure for the enrollee's back pain. The Plan states this is not an accepted standard of medical practice for 
the treatment of back pain. The Plan states trials determining the efficacy and safety of this procedure currently 
in effect exclude patients with disc protrusion and facet arthropathy which are conditions the enrollee displays 
or for which the enrollee is receiving treatment. 
 
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this an experimental/ investigational procedure. Therefore, the request is deemed not 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral 
disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker (E0144) and sales tax (S9999), provided on 
March 21, 2022. 
 
You asked the Plan to pay for the walker and sales tax. You say that the items should be covered. The Plan 
denied your request. The Plan says this was obtained through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker (E0144) and sales tax 
(S9999), provided on March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery; intermediate (77523). 
 
You asked the Plan to pre-approve proton treatment delivery. You say that the requested therapy is medically 
necessary as the enrollee's case is not routine in nature. The Plan denied your request. The Plan says the request 
is not medically necessary. A review of the literature indicates that PBRT is not the standard of care for 
prostate cancer and proton beam therapy for primary treatment of prostate cancer should only be performed 
within the context of a prospective clinical trial. 
 
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 proton treatment delivery. 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 clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a 
possible advantage of this expensive therapy. Proton therapy for prostate cancer is not experimental, and in fact 
is an accepted treatment approach. Any potential benefit or detriment of proton therapy over standard IMRT is 
an investigational question (being pursued in randomized studies). Other treatment approaches (IMRT +/- 
IGRT) are also highly effective and well tolerated. Thus, whether proton therapy affords a benefit over other 
standard approaches (IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial. To 
date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than 
IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy 
on clinical trials, and to not routinely offer it to enrollees. The decision is unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery; intermediate (77523).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
  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. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of SSBCI benefits have been met. Therefore, we decided that the Plan does not 
have to pre-approve SSBCI benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says the requested power wheelchair cannot be 
replaced since it is less than five years old. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment 
cannot be less than 5 years. 
 We looked at the file and Medicare rules. The record shows you received your current power wheelchair in 
July 2018. Your power wheelchair is less than five years ago and cannot be replaced. As the power wheelchair 
is not covered the requested accessories are denied. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 power wheelchair (K0861) and accessories.