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

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 oxygen concentrator Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found you have congestive heart failure and obstructive sleep apnea and are 
on home oxygen. The documentation does not include testing to document that your oxygen saturation can be 
maintained over 91% using an oxygen conserving device at one to four liters per minute. Therefore, you do not 
meet criteria for the requested portable oxygen concentrator. 
 
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 oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth, or exposed root (elevation 
and/or forceps removal) (D7140) Tooth #25 and 26. 
 
You asked the Plan to pre-approve dental services. You say that you have a couple of teeth that are lose and 
you need to get them extracted. You would like your insurance to pay for the service. The Plan denied your 
request. The Plan says this service is not covered under your Plan. 
 
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. Extraction, erupted tooth, or 
exposed root (elevation and/or forceps removal) (D7140) is not covered under the Plans dental benefits. 
 
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 
extraction, erupted tooth, or exposed root (elevation and/or forceps removal) (D7140) Tooth #25 and 26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with single power 
option (K0856), joystick armor (K0108), electronic connection (E2311), harness (E2313), and expandable 
controller (E2377). 
 
You asked the Plan to pre-approve a group 3 power wheelchair (PWC) with single power option with addition 
features. You say that these items are medically necessary. The Plan denied your request. The Plan says these 
items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with single power option and added 
features are covered when the criteria listed in the Medicare Rules section 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 3 power wheelchair (PWC) 
with single power option with addition features. Our reviewer says that these items are not medically 
necessary. Our physician reviewer found the power mobility evaluation provided is largely illegible and the 
patients level of function and physical examination findings cannot be assessed to determine his ability to 
perform pressure relief and the need for power tilt and a group 3 power wheelchair. Even if the patient requires 
power tilt, this should be attainable with an appropriately modified group 2 power wheelchair. A group 3 power 
wheelchair base in typically required in patients that require multiple power options, including power tilt and 
recline and power elevating leg rests that must be simultaneously controlled. 
 
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 3 power wheelchair (PWC) with single power option with addition 
features have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair (PWC) with single power option (K0856), joystick armor (K0108), electronic connection (E2311), 
harness (E2313), and expandable controller (E2377).
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. The Plan denied your request. The Plan says the enrollee's records 
received do not indicate a need for an intensive therapy program with multiple visits from a rehabilitation 
doctor per week. The enrollee may safely receive the services needed in other settings, a skilled nursing 
facility, home with home health and home physical therapy. 
 
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 there is not a reasonable expectation that the 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve an EGD. The Plan denied your request. The Plan says this service is not 
medically 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 an EGD. Our reviewer says that an 
EGD is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee has gastroesophageal reflux controlled with medication. The records provided are insufficient to 
establish the medical necessity of the requested procedure at this time. Our reviewer found that the record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied. Our physician reviewer also found 
that the requested service is not 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 an EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an esophagogastroduodenoscopy (EGD) (43235).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services (76641-LT, 76641-RT) provided on October 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that code 76641 has an 
MUE value of 1, but 2 units were billed. 
 
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 code 76641 has an MUE of 1, however, a CPT code search 
reveals that code 76641 has an MUE value of 2. Additionally, Medicare rules say that a bilateral diagnostic 
procedure may be reported with 1 unit of service with modifier RT on 1 claim line plus 1 unit of service 
and modifier LT on a second claim line, as was done in this case. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (76641-LT, 
76641-RT) provided on October 3, 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 stairway elevator (E1399). 
 
You asked the Plan to pre-approve a stairway elevator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is a convenience item and not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a stairway elevator (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the member did not use the CPAP device for the required amount of time. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must conduct a clinical re-
evaluation with documentation that you are benefiting from CPAP therapy. Additionally, you must use your 
CPAP for at least 21 days/nights for 4 or more hours while sleeping during a 30-day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, the member did not use the CPAP device for the 
required amount of time. Therefore, we decided that the Plan does not have to pre-approve a continuous 
positive airway pressure (CPAP) device (E0601).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would benefit from a SNF stay to increase 
mobility and strength and help your chances of being successful at home. The Plan denied your request. The 
Plan says the SNF services you are requesting do not meet the requirements for approval. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You 
are consistently ambulating more than 100 feet and tending to activities of daily living with minimal 
supervision. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs, custodial and intermittent, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 sensor. You say that you disagree with the denial of the 
Freestyle Libre 3 sensor. The Plan denied your request. The Plan says that you are requesting a CGM product 
that does not meet Medicare's definition of durable medical equipment (DME) and, therefore, is not in a 
defined Medicare benefit category. 
 
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 records show that you are requesting coverage of a non-
adjunctive CGM. As of January 1, 2023, the appropriate coding for a non-adjunctive CGM is E2103. The 
Freestyle Libre 3 is not specified as a product that may be billed using code E2103. Therefore, the Freestyle 
Libre 3 is not eligible for reimbursement. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 3 sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 3 sensor.
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 you have been having frequent falls, balance issues 
and worsening weakness. You say that you have to hold onto furniture in order to walk and your right side is 
weaker than your left side. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and you can receive the care you need 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 you are medically stable and do not require close supervision for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While you can benefit from 
physical and occupational therapy, your needs can be safely provided in an alternate level of care such as a 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for admission to an IRF. 
 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services with regular physician evaluation. The enrollees care needs can be met at a lower 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 a home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that your Pulmonologist requested a ventilator 
because you are not getting enough oxygen into your lungs and blood stream with the BiPaP. The Plan denied 
your request. The Plan says this 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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has very severe chronic obstructive pulmonary disease (COPD) with 
frequent hospitalizations and is being evaluated for lung transplantation. The enrollee is currently on bilevel positive airway pressure (BiPAP) at home.  Arterial blood gas (ABG) done as an outpatient on August 24, 
2022, the day the enrollee was admitted, while on BiPAP, showed a normal partial pressure of carbon dioxide 
(PaCO2) of 40. BiPAP is therefore adequate to support the enrollee's ventilatory needs. It would be reasonable 
to try adding average volume-assured pressure support (AVAPS) mode to the BiPAP for additional relief from 
the dyspnea.  Medicare does not cover a home ventilator when used as BiPAP. Of note, the inpatient clinical 
notes refer to obtaining the Life2000 system, rather than a true ventilator. This system has not been 
demonstrated to be effective in the treatment of COPD and is therefore 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crowns (D6750) for tooth #'s 12 and 14. 
 
You asked the Plan to pre-approve the retainer crowns. You say that you would like to appeal these services. 
The Plan denied your request. The Plan says that the documentation does not meet the Plan's clinical criteria for 
coverage. 
 
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 did not provide digital quality x-rays for this case. We asked for this 
document, but it was not provided to us. Without this information we cannot determine if the requested service 
is not medically necessary, or does not meet the criteria for coverage. Consequently, the Plan has not 
substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pre-approve 
retainer crowns (D6750) for tooth #'s 12 and 14.  
 
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 bone growth stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the device will help the enrollee heal 
and reduce fall risk. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. 
 
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not 
show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had 
ceased. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator.