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

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. The records do not show that adaptive support ventilation (ASV), or bilevel positive airway pressure 
(BiPAP) with volume assurance, has been tried as an outpatient. There are no device downloads indicating 
compliance with past therapy.  Reportedly the enrollee had a home ventilator in the past which was returned 
because of noncompliance.  Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. a home ventilator is not medically necessary. The records do not show that adaptive 
support ventilation (ASV), or bilevel positive airway pressure (BiPAP) with volume assurance, has been tried 
as an outpatient. There are no device downloads indicating compliance with past therapy.  Reportedly the 
enrollee had a home ventilator in the past which was returned because of noncompliance.  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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro. 
 
You asked the Plan to pre-approve Neulasta Onpro. 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 Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta Onpro. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is receiving a 
chemotherapy regimen with low risk of febrile neutropenia (FN). He does not have two risk factors such as 
previous neutropenic fever complication, dose-limiting neutropenic event or is receiving a dose-dense chemo regimen on review of the medical records given. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta Onpro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Neulasta Onpro.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45378). 
 
You asked the Plan to pre-approve a colonoscopy. 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 a colonoscopy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for the indication, of 7 tubular adenomas, the appropriate surveillance window is 3 years; that 
said, if there is concern for an incomplete exam then will need to rebill and place a new referral that would be 
indicated.  
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 colonoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy (45378).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair with a patient weight capacity up to and including 300 pounds (K0823) and a U-1 sealed lead acid battery (E2365).

 
You asked the Plan to pre-approve a Group 2 standard power wheelchair and a U-1 sealed lead acid battery. You say that your current wheelchair is not charging correctly. You say that the records from your provider support the need for item in dispute. The Plan denied your request. The Plan says the requested power wheelchair does not meet criteria.

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 patient's 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 Group 2 standard power wheelchair and a U-1 sealed lead acid battery. Our physician reviewer found there is no documentation that you can safely operate the requested power mobility device or that the requested device is safe for you. You are reported to weigh in excess of 400 pounds, and the weight capacity of the requested Group 2 standard power wheelchair (K0823) is 300 pounds. Our reviewer found that the health plan has provided an authorization which is in progress for approval for repair of your current power wheelchair. Our physician reviewer also found that the records do not clarify that repair of your present power wheelchair would not meet your 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 Group 2 standard power wheelchair and a U-1 sealed lead acid battery have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair with a patient weight capacity up to and including 300 pounds (K0823) and a U-1 sealed lead acid battery (E2365). 

Please Note: The records show that the report for repairs to your current wheelchair is currently under review per authorization number ending in *3717. Please contact the Plan if you have questions regarding this request
.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography provided on June 09, 2022.

You asked the Plan to pay for the computed tomography. You say that you are requesting reconsideration of the denied claim. 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 the computed tomography provided on June 09, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction of wisdom tooth (41899 and 21040). 
 
You asked the Plan to pre-approve the dental services. You say that you have recurrent pain associated with 
tooth 17. You state this tooth has recurrent pericoronitis and there is a lesion associated with tooth 32 and tooth 
31 requires restoration and the presence of tooth 32 prevents the treatment of tooth 31. You state complete 
removal of tooth 32 with enucleation of the associated lesion is indicated to prevent further mass effect, 
potential spread of lesion, and to determine a definite diagnosis. You say all of these procedures are medically 
necessary and due to your complex medical history, outpatient general anesthesia in the operating room is the 
only safe setting. You say the procedure cannot be performed in an office-based setting due to your history of 
sarcoidosis and multiple other co- morbidities. The Plan denied your request. The Plan says the services are not 
covered by Medicare or the Health 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. 
 
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. According to the records, you are not receiving radiation therapy to the 
mouth or jaw, and you do not have a diagnosis of Temporomandibular Joint Syndrome (TMJ). Therefore, your 
request for Dental Services for extraction of wisdom tooth is not a covered benefit by Medicare and has been 
denied. Therefore, we decided that the Plan does not have to pre-approve extraction of wisdom tooth (41899 
and 21040).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. 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 stress testing with cardiac imaging will be considered 
medically reasonable and necessary under certain circumstances. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no evidence 
provided that would support the need for radionuclide stress testing. In summary, there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing in this enrollees 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 myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee's physician is appealing with medical 
records. The Plan denied your request. The Plan says the enrollee is not on insulin and there are no documented 
hypoglycemia episodes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found coverage criteria for CGM require insulin use or low blood glucose sugar (BGS). Our physician reviewer 
was not told of low BGS and although the enrollee is taking glimperide that can cause low BGS, none are 
noted. Therefore, although the CGM may help the enrollee, the coverage criteria for CGM are not met and our 
physician reviewer is also not told why a fingerstick meter would not suffice. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G7 continuous glucose monitor (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on July 4, 2023. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the provided CGM was medically 
necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided 
CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the continuous glucose monitor. Our 
reviewer says that the enrollee did not meet criteria for the provided CGM. Our physician reviewer found the 
record indicates that the enrollee has diabetes. The record provided includes a provider note from May 2022. 
The record provided does not indicate that the enrollee within six (6) months prior to ordering the CGM, the 
treating practitioner had an in-person or Medicare-approved telehealth visit with the beneficiary to evaluate 
their diabetes control. The elements of the coverage criteria are not satisfied.  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 the continuous glucose monitor have not been met. Therefore, we decided that 
the Plan does not have to pay for the continuous glucose monitor provided on July 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient care provided from January 9, 2024, 
forward. 
 
You asked the Plan to pre-approve continued inpatient care. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records show that the enrollee was hemodynamically 
stable with no acute abnormalities. The Plan also says that continued inpatient level of care 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 continued inpatient care. Our reviewer 
says that the requested continued inpatient care is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records do not support a need for continued inpatient 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 continued inpatient care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient care provided from January 9, 2024, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external infusion pump. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an external infusion pump is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not support 
that the criteria for coverage of the requested external infusion pump are met. The services are not reasonable 
or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an external infusion pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical stimulation device used for cancer 
treatment, includes all accessories, any type (Tumor treatment field therapy, or TTFT) (E0766). 
 
You asked the Plan to pre-approve TTFT. 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 tumor treatment field therapy (E0766) is covered for 
the treatment of newly diagnosed Glioblastoma Multiforme (GBM) only when all 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 TTFT. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the records 
do not demonstrate that the enrollee has a Glioblastoma Multiforme. The review has determined that the 
enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTFT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an electrical stimulation device used for cancer treatment, includes all accessories, any type 
(Tumor treatment field therapy, or TTFT) (E0766).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair with single 
power option (tilt, legrests) and accessories. 
 
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair with single power option. You say 
that this is medically necessary for the enrollee. The Plan denied your request. The Plan says the notes do not 
show a medical need for the requested power option. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 heavy duty power wheelchair with single 
power option may be covered when the 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 3 heavy duty power wheelchair 
with single power option. Our reviewer says that the requested Group 3 heavy duty power wheelchair with 
single power option is not medically necessary. Our physician reviewer found the documentation does not 
indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder or have 
spasticity that would necessitate power tilt. Therefore, the reviewer found that the requested Group 3 heavy 
duty power wheelchair is 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 a Group 3 heavy duty power wheelchair with single power option have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair 
with single power option (tilt, legrests) and accessories.
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 only an inpatient rehabilitation hospital can offer the 
comprehensive medical oversight, specialized therapies and expert support necessary to facilitate your healing 
journey. The Plan denied your request. The Plan says the request is not medically necessary.  
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical or occupational therapy, at an intensive rehabilitation 
therapy program. You continue to have a need for skilled therapy however, the documentation doesnt support 
that you meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least three visits weekly to regain or maintain your functional status. You 
can receive further 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 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.