Persius/hicric huggingface dataset:
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF is not medically necessary. 
 
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 the enrollee does not require daily skilled nursing or skilled therapy services. The 
enrollee's physical function is at or near their baseline and can receive services 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac-joint fusion procedure (27280). 
 
You asked the Plan to pre-approve a sacroiliac-joint fusion. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. 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 sacroiliac-joint fusion. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of sacroiliac-joint fracture, instability or lesion. The enrollee has 
degenerative low back pain. Sacroiliac-joint fusion for degenerative back pain is experimental. 
 
 
  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 sacroiliac-joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac-joint fusion procedure (27280).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-frequency chest-wall oscillation device 
(HFCWOD) (E0483). 
 
You asked the Plan to pre-approve an HFCWOD. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of an HFCWOD have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
 
  The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high-frequency chest-wall oscillation device (HFCWOD) (E0483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and related 
supplies (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and related supplies. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for OON care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. 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 pneumatic compression device and related supplies. Our reviewer says 
that the requested items from an OON provider are not medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee would be a candidate for a pneumatic compression device. However, 
the documentation is not clear why the requested Medi Brio lymphedema pump provided by an OON provider is medically necessary versus a standard lymphedema pump. The letter of appeal indicates that would healing 
would be impaired if another device is used, but there is no explanation as why this would specifically be the 
case. There has been no trial of a standard device and objective measurements that a standard device failed to 
reduce the enrollees lower extremity edema. 
 
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 pneumatic compression device and related supplies have not been met. We 
found no exception that would require the Plan to pre-approve a pneumatic compression device and related 
supplies. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0651) and related supplies (E0667) to be provided by an out-of-network (OON) provider.
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 had a hip replacement surgery for the 
second time on the same hip. The 2nd surgery is more invasive, and the enrollee requires inpatient rehab to 
maintain independence. The enrollee needs to get back to baseline and cannot walk, sit, or stand. The Plan 
denied your request. The Plan says the request is not medically necessary, the services the enrollee needs can 
be provided safely in other settings, for example, a skilled nursing facility. 
 
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 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve surgery to be provided by an OON provider. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
neither emergent nor urgent to seek out-of-network care. The Plan says that there are equally qualified in-
network surgeons available to the enrollee that can provide the surgery you are requesting. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
surgery to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the requested left heart 
catheterization is medically necessary. The Plan denied your request. The Plan says the requested left heart 
catheterization 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 left heart catheterization. Our reviewer 
says that the requested left heart catheterization is not medically necessary. Our physician reviewer found the 
enrollee had a negative radionuclide stress test in 2020. He has had no chest pains. Documentation does not 
reveal the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization 
in this setting. As a result, at this time cardiac catheterization would not be considered medically appropriate 
and necessary in this enrollee's 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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has a respiratory status that 
can only be managed at the LTACH level. The Plan denied your request. The Plan says criteria for admission 
to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in need of long-term acute 
care hospital admission. The Plan denied your request. The Plan says the enrollee can safely receive care in 
another setting, such as: an Inpatient Rehabilitation Facility (IRF), a Skilled Nursing Facility (SNF) or at home 
with home health services or outpatient setting if appropriate. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that you have complex functional impairments and many active medical 
issues/active medical comorbidities thus, you would be expected to require inpatient hospitalization with an 
interdisciplinary approach to rehabilitation care. Evaluating therapists recommend ongoing skilled therapy in 
an inpatient rehabilitation setting. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 Dexcom G7 receiver. 
 
You asked the Plan to pre-approve a Dexcom G7 receiver. You say that the requested Dexcom is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G7 
receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 
receiver.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seating system, 
combination tilt and recline, with mechanical shear reduction (E1007). 
 You asked the Plan to pre-approve a wheelchair accessory. You say that the enrollee has imbalance and 
weakness. The enrollee needs assistance with standing up and transfers. His physician, and physical therapist 
are recommending and prescribing a power tilt seating system since he is unable to stand for regular pressure 
relief. The enrollee is unable to perform a functional substantial offloading weight shift, secondary to shoulder 
weakness. The Plan denied your request. The Plan says the notes say that the enrollee would like to have the 
special accessories in order to tilt backward for one minute every hour. The Plan also says the request does not 
seem reasonable as there is no other medical reason given for why this is needed for one minute every hour 
schedule. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the enrollee does not appear to require and is 
not meeting the medical necessity and established criteria for the requested tilt in space and recline. The 
enrollee can weight shift and is continent of urine and stool and does not require catheterization as a rationale 
for this addition to the approved group 3 PWC.  There is no history of pressure ulceration and the notes do not 
indicate good sitting balance to not require the tilt in space for maintenance of posture. Based on this 
information, we decided that Medicare rules for coverage of a wheelchair accessory have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a wheelchair accessory, power seating 
system, combination tilt and recline, with mechanical shear reduction (E1007).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components, and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve a MyoPro myoelectric orthotic device. You say that with practice, the 
enrollee can very quickly regain their arm function for practical ADL/IADL completion, improving their 
independence at home, and therefore avoid overuse injuries to the unaffected arm as well as other 
complications inherent in sedentary living. The Plan denied your request. The Plan says experimental and 
investigational procedures are not covered by Medicare. 
 
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 MyoPro myoelectric orthotic device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the clinical documentation does not support that the MyoPro Motion G 
Orthotic device is medically reasonable and necessary for the enrollee in this case. The clinical documentation 
does not support that the requested orthotic device is an accepted standard of medical practice that meets but 
does not exceed the enrollee's medical need and does not indicate that the device is at least as beneficial as 
existing and available medically appropriate alternatives. There is insufficient medical literature with controlled 
studies demonstrating the efficacy of this device. Controlled trials do not support that daily function is 
improved with the use of the device. Studies to date are of small size and take place in controlled environments. 
Additional studies are necessary to establish efficacy. The evidence is insufficient to determine the effects of 
this technology on health outcomes. There are insufficient long-term data for the use of this device. 
 
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 MyoPro myoelectric orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity range of motion assist device, elbow, 
wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components, and 
accessories, custom fabricated (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Left Heart Catheterization (93458). 
 
You asked the Plan to pre-approve a Left Heart Catheterization. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the 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 a Left Heart Catheterization. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found radionuclide stress test was normal in 2022, with echocardiogram showed a normal 
ejection fraction. The medical records provided do not support the rationale for this invasive imaging study. 
Guidelines do not support a need for cardiac catheterization in this setting. 
 
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 Left Heart Catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Left Heart Catheterization (93458).