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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for a CGM. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a qualifying diagnosis for a group 3 power wheelchair.  
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that tthere is 
insufficient clinical documentation regarding the patients medical history in terms of the severity of her heart 
failure and lymphedema. There is limited documentation regarding the severity of the patients lower extremity 
edema. Without this information, it cannot be determined if the requested group 2 power wheelchair with 
power tilt/recline, and power elevating foot platform is appropriate and medically necessary. The patient does 
not have a diagnosis of a neurological condition that would necessitate a group 3 power wheelchair, but it 
appears that a group 2 power wheelchair is being requested. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance service provided on August 31, 2022. 
 You asked the Plan to pay for the air ambulance service. You say that due to the critical status of the patient's 
condition, transport was critical, airtime of 31 minutes versus ground time of 89 minutes. The Plan denied your 
request. The Plan says the air ambulance transport was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for the air ambulance service. Our reviewer says 
that the air ambulance transport was not medically necessary. Our physician reviewer found the enrollee was 
evaluated in the local emergency department for abdominal pain. The enrollee was found to have pancreatitis 
and evidence of new metastasis. The decision was made to transfer the enrollee for a higher level of care. The 
transfer was complicated by lack of beds, resulting in transfer to a facility that was further away. While the 
transfer was itself reasonable, the enrollee appears to have been clinically stable enough to have been 
transported by ground transportation. The use of an air ambulance was not medically necessary or reasonable. 
 
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 air ambulance service have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance service provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee needs the wheelchair to help 
make her daily life better. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for a power wheelchair. Additionally, Medicare wants the justification to be specific. Increasing difficulty is 
just too broad and is to be left to interpretation. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 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 power wheelchair. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has diabetic neuropathy, 
cognitive loss, and functional impairment. Per chart notes, the enrollee is unsafe to drive a wheelchair. Per 
physician notes, she is independent in transfers and toileting but unsafe to drive a power wheelchair. The record 
does not address why a manual wheelchair is insufficient for her needs. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro device. 
 
You asked the Plan to pre-approve a MyoPro device. 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. 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 device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had a left brachial plexus injury on August 2, 2013. The Myomo 
evaluation also notes the enrollee has a spinal cord injury. The enrollee has tried and failed physical therapy 
and occupational therapy. The MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollees condition or in widespread use for this enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for patients with stroke, brachial plexus injury, traumatic brain injury, and other neuromuscular disorders. 
There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Therefore, the enrollee does not meet criteria for the requested 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 device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro device.
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 enrollee requires assistance improving daily 
functions due to current medical condition. The Plan denied your request. The Plan says IRF services requested 
do not meet the requirements for approval. 
 
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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve the ESI. You say that your pain radiates down your arm. You say your pain 
is worse in your mid-back area. You also say that your pain impacts your daily life. The Plan denied your 
request. The Plan says the requested injection is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when all the requirements 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 the ESI. Our reviewer says that an ESI 
is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
imaging shows central or foraminal stenosis. Therefore, the reviewer found that the requested ESI is not 
medically reasonable or necessary at this time. 
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI) (62321).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wellness visit provided on August 05, 2022. 
 
You asked the Plan to pay for wellness visit. You say that you could not find any other provider in your area 
accepting new patients. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wellness visit provided 
on August 05, 2022.
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 you are appealing the denial. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 your 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for dialysis. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says network providers must be used. 
 
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 
an out-of-network referral for dialysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on 
August 30, 2022. 
 
You asked the Plan to pay for the PCD. You say that this item was prescribed following surgery to prevent 
thrombotic events. You said that this item should be covered. The Plan denied your request. The Plan says this 
item is not covered. The Plan must follow Medicare rules. Medicare rules say that that PCDs used for the 
prevention of thrombotic events are explicitly non-covered.  The records and your appeal letter confirm that the 
PCD at issue in this case was provided solely for the prevention of thrombotic events following surgery. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) 
provided on August 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that a PET scan is medically necessary. The Plan 
denied your request. The Plan says a PET scan is not medically necessary and does not meet the Medicare 
NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan. Our reviewer says that a 
PET scan is not medically necessary in this case. Our physician reviewer found the enrollee is a 75-year-old with a tumor identified by needle biopsy found in one or both sides, but not palpable (cT1c), Gleason's grade 
4+3 and 3+3 adenocarcinoma of the prostate with baseline prostate-specific antigen (PSA) of 7.9 ng/mL. The 
enrollee has chosen radiation as the preferred treatment option. A PET scan is not medically necessary and 
does not meet the Medicare NCD coverage criteria in this case. According to the current American Urological 
Association (AUA) guidelines: Clinicians should not routinely perform abdominopelvic computed tomography 
(CT) scan or bone scan in asymptomatic patients with low- or intermediate-risk prostate cancer. Clinicians 
should obtain a bone scan and either pelvic multi-parametric magnetic resonance imaging or CT scan for 
patients with high-risk prostate cancer. (Strong Recommendation; Evidence Level: Grade B) In patients with 
prostate cancer at high risk for metastatic disease with negative conventional imaging, clinicians may obtain 
molecular imaging (PET scan) to evaluate for metastases. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression devices (E0650, E0673, 
E0666) provided from December 3, 2021, to December 27, 2021. 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the requested items were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items exceed the 
enrollee's medical need. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pay for intermittent limb compression devices. Our 
reviewer says that the requested items are not medically reasonable and necessary in this case. Our physician 
reviewer found that there is no evidence of marked hyperkeratosis with hyperplasia and hyperpigmentation, 
papillomatosis cutis lymphostatica, deformity of elephantiasis, skin breakdown with persisting lymphorrhea or detailed measurements over time confirming the persistence of lymphedema with a history evidencing a likely 
etiology. The documentation does not reveal a history and objective physical examination consistent with 
lymphedema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression devices have not been met. Therefore, we 
decided that the Plan does not have to pay for intermittent limb compression devices (E0650, E0673, E0666) 
provided from December 3, 2021, to December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power lift chair provided on June 2, 2021. 
 
You asked the Plan to pay for the power lift chair. You say that the item should be covered. The Plan denied 
your request. The Plan says this was obtained through a provider that is not Medicare-certified. 
 
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 power lift chair provided on June 2, 
2021.
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 enrollee needs an IRF admission for close 
follow-up care. The Plan denied your request. The Plan says the documentation does not indicate that there are 
co-comorbidities that would require close supervision by a physician; nor is there documentation that there is 
need for a required intensive and coordinated interdisciplinary approach to providing rehabilitation. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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.