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

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has chronic obstructive pulmonary disease (COPD) and was recently hospitalized with 
a COPD exacerbation triggered by influenza. There is no arterial blood gas (ABG) done while stable to 
document chronic carbon dioxide (CO2) retention. If the enrollee does have chronic CO2 retention, may 
benefit from bilevel positive airway pressure (BiPAP) with average volume assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided by 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0856, 
E0955, E1002, E1012, E1028, E2310, E2313, E2361, E2377, E2603, E2620, K0040). 
 
You asked the Plan to pre-approve power wheelchair and accessories. You say that you were diagnosed with 
Huntington's disease, and this is the power wheelchair that was recommended by the provider. The Plan denied 
your request. The Plan says the requested power wheelchair is not reasonable and necessary, none of the 
requested accessories can be 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 power wheelchair and accessories. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a power mobility evaluation dated December 28, 2022, indicated that you 
have poor mobility and upper extremity weakness with involuntary movement. You can transfer to and from a 
power wheelchair. You are functionally non-ambulatory and cannot use a cane or walker for mobility due to 
weakness and increased risk for falling. You cannot functionally propel a manual wheelchair due impaired 
coordination from your Huntingtons disease. Your home does not allow for the operation of a power scooter 
due to its increased turning radius. You require a power wheelchair for mobility and accomplishing your daily 
activities. However, the clinical documentation is insufficient as to why a lower-level power wheelchair, such 
as a group 2 power wheelchair, would not suffice for your needs versus a group 3 power wheelchair. You have 
4/5 motor strength in the upper extremities and should be able to independently perform pressure relief. There 
is no history of skin breakdown, and you do not require a power tilt option. There is also inadequate clinical 
documentation regarding why you require power elevating leg rests. There is not noted lower extremity 
lymphedema or spasticity. Therefore, the group 3 power wheelchair with power tilt and power elevating leg 
rests is not 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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0856, E0955, E1002, 
E1012, E1028, E2310, E2313, E2361, E2377, E2603, E2620, K0040).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary 
due to the patient's chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan 
says the patient's needs can be met with bi-level positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS). 
 
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 home ventilator is not medically necessary. Our physician reviewer found This patient has 
COPD and was recently hospitalized with acute pulmonary edema.  Arterial blood gas was consistent with 
acute on chronic hypercarbic respiratory failure.  The patient improved on BiPAP, and was discharged with a home ventilator.  The etiology of the CO2 retention is likely a combination of COPD and chronic narcotic 
use. The patient may benefit from BiPAP with AVAPS during sleep as an outpatient.  Medicare does not cover 
a home ventilator when used with settings that can be provided by 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.
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 is in need of the ventilator. The 
enrollee had a BIPAP for over 5 years per the documentation and it is no longer providing adequate benefit. 
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 severe COPD and 
obstructive sleep apnea and has been on BiPAP for several years as treatment for the sleep apnea. The clinical 
note describes an arterial blood gas showing CO2 retention, but the data and circumstances of the test are not 
provided. If this enrollee does have chronic CO2 retention, as documented on ABG while stable, he may 
benefit from BiPAP with AVAPS and a backup rate. Medicare does not cover a home ventilator when used at 
settings that can be provided by 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: 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 this is medically necessary. The Plan denied your 
request. The Plan says you are not eligible for SNF coverage. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you are functioning at a home care level and do not require daily skilled services 
to restore or maintain function. You do not require skilled nursing and have not been hypoxic. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. 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 and 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 a group 2 standard power wheelchair. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the coverage 
criteria is not met as the home evaluation is incomplete. The record state he has trace weakness in his arms but 
is too weak to manage a wheelchair. Trace weakness does not prevent use of a manual wheelchair. 
 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 group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve canal preparation and fitting of dowel (D3950) and a 
surgical procedure for isolation with rubber dam (D3910). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the 
denial of the dental services. The Plan denied your request. The Plan says these services are not covered, and 
there is no separate payment for procedures which are an integral part of an approved procedure. 
 
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 canal 
preparation and fitting of dowel (D3950) and a surgical procedure for isolation with rubber dam (D3910).
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 COVID 19 pneumonia. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a FreeStyle CGM system. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee does not have a diagnosis of diabetes and is not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a 
diagnosis of diabetes, does not use insulin with at least three daily injections or require frequent self-adjustment 
of insulin dosage based on the blood glucose testing results. Based on this information, we decided that 
Medicare rules for coverage of a FreeStyle CGM system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this device is medically necessary. The Plan 
denied your request. The Plan says a ventilator is not medically necessary for this patient. 
 
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 home ventilator is not medically necessary. Our physician reviewer found this patient has 
severe chronic obstructive pulmonary disease (COPD), heart failure with preserved ejection fraction, 
pulmonary hypertension, and a prior mitral valve replacement. The patient was recently hospitalized with a 
COPD exacerbation secondary to rhinovirus infection.  Arterial blood gas was consistent with acute on chronic 
hypercarbic respiratory failure.  The patient improved on Bi-level positive airway pressure (BiPAP).  The patient may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided by 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.
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 are in pain, and you need the DME 
equipment to help with breathing. You believe that your health condition is affecting the quality of your life 
and the ventilator would be very beneficial for you. The Plan denied your request. The Plan says the requested 
device would be used in a BiPAP mode that could be provided with a BiPAP (E0471) device with AVAPS-AE 
added to assure adequate tidal volumes. 
 
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 were recently hospitalized with a 
COPD exacerbation. Arterial blood gases were consistent with acute on chronic hypercarbic respiratory failure.  
There are no pulmonary function tests to assess severity of the COPD. There is no ABG done while stable to 
confirm chronic CO2 retention. If you do have chronic CO2 retention, you may benefit from BiPAP with 
AVAPS and a backup rate during sleep 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 you were independent before your hospitalization 
and want to return home independently. The Plan denied your request. The Plan says your 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 the records show that you do not require intensive rehabilitation or frequent 
oversight.  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulsed electrical field ablation. 
 
You asked the Plan to pre-approve pulsed electrical field ablation. 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 pulsed electrical field ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the clinical value and effectiveness of Pulsed Electrical Field Ablation in 
the setting of recurrent granulosa cell tumor have not been demonstrated in the peer-reviewed literature. The 
review has determined that the items/services at issue in this case are 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 pulsed electrical field ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pulsed electrical field ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23430-AS-59-RT provided on October 3, 
2022. 
 You asked the Plan to pay for procedure code 23430-AS-59-RT. You say that the medical records support the 
use of modifier 59 with code 23430. The Plan denied your request. The Plan says the medical records do not 
support the use of modifier 59 with code 23430. 
 
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, we have confirmed that code 23430 is a column II code to column I code 23472; however, 23430 
was billed with a modifier.  
 
We asked our coder 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 procedure code 23430-AS-59-RT. Our reviewer says that the 
medical records do not support the use of modifier 59 with code 23430. Our reviewer found the operative 
report describes tenodesis of long tendon of biceps and total shoulder arthroplasty on the right side, and in this 
case tenodesis would be included in shoulder arthroplasty and not reported separately. Modifier 59 is not 
supported in the medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 23430-AS-59-RT have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 23430-AS-59-RT provided on October 3, 2022.