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

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller. You say that when three or more power seating functions/actuators/motors are provided, one unit of 
E2311, one unit of E2377, and one unit of E2313 are allowed. The Plan denied your request. The Plan says an 
electronic connection, harness, and expandable controller cannot be covered as they are not medically 
necessary to control the three approved power options through the joystick (drive interface). 
 
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 electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the provided records 
were completely re-reviewed on November 29, 2023. Provided records document that the enrollee has 3-/5 to 
3/5 bilateral upper extremity strength and is independent with feeding thus indicating she has adequate upper 
extremity strength and function to operate the wheelchairs power options with their own switches. 
 
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 electronic connection, expandable controller harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), harness (E2313), and expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and a non-pneumatic sequential compression garment, half leg (K1033). 
 
You asked the Plan to pre-approve a non-pneumatic compression device and garment. You say that the 
requested device is determined to be safe and effective and is a Food and Drug Administration (FDA) cleared 
prescription-only medical device indicated for the treatment of lymphedema, venous insufficiency, and 
reducing wound healing time. The Plan denied your request. The Plan says current evidence does not support 
durable medical equipment in this clinical scenario. The use of a Koya Dayspring non-pneumatic device is 
unproven. 
 
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 non-pneumatic compression device 
and garment. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the physician progress note documentation indicates 
venous insufficiency. This conflicts with the July 31, 2023, Dayspring medical necessity document checklist 
and letter of appeal which indicates the enrollee has lymphedema. The documentation does not reveal any 
physical examination evidence of lymphedema in the physician clinical documents. There are insufficient 
large-scale long-term studies for the use of this device for lymphedema or venous insufficiency. The requested 
Dayspring device is not the standard of care at this time for either lymphedema or chronic venous 
insufficiency. 
 
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 non-pneumatic compression device and garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a non-pneumatic compression controller with 
sequential calibrated gradient pressure (K1024) and a non-pneumatic sequential compression garment, half leg 
(K1033).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar laminectomy (63047, 63048) to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a lumbar laminectomy with an out-of-network provider. You say that you 
want to see this provider. The Plan denied your request. The Plan says this provider is out-of-network. The 
services are available in-network. 
 
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 
a lumbar laminectomy (63047, 63048) 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this care to regain 
maximum function. The Plan denied your request. The Plan says the enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
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 in their current acute care setting. The 
documentation does not support that LTACH services are medically, reasonable and appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is necessary 
because nursing home facilities will not accept the enrollee due to current condition. The Plan denied your 
request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 hemodynamically stable, has completed antibiotics, is receiving total 
parenteral nutrition (TPN), and wound care for a stage 2 pressure injury. The results of the enrollee's 
lymphoproliferative or myeloproliferative disorder workups are still pending. The enrollee is making good 
progress and is unlikely to need LTACH for >25 days. No therapeutic benefit to LTACH transfer is anticipated. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the record suggests the enrollee has 
Alzheimer's disease. The record provided does not establish that the enrollee meets the diagnostic criteria of 
both AD and FTD. The elements of the coverage criteria are not satisfied. The requested service cannot be 
covered 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #8 and #9. 
 
You asked the Plan to pre-approve core buildup (D2950) for tooth #8 and #9. You say that you are requesting a 
fast appeal with radiographs and intraoral pictures showing severe fracture lines on tooth #8 and #9. The Plan 
denied your request. The Plan says this service is not a covered expense under the enrollee's dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950) for tooth #8 and #9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a raised toilet seat. 
 
You asked the Plan to pay for a raised toilet seat. You say that you need this item. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power option (K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2300, 
E2311, E2313, E2323, E2363, E2377, E2605, and E2613). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that you have found the requested services to be both medically necessary and covered, under 
Medicare guidelines. The Plan denied your request. The Plan says the enrollee does not have medical need for 
multiple power options included with a K0861 Group 3 power wheelchair. The Plan also says the electronic 
connection, expandable controller harness, and expandable controller cannot be covered as it is not medically 
necessary to control the three requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
  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 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee requires a power wheelchair for mobility and accomplishing their daily 
activities. However, the clinical documentation is insufficient why a lower-level power wheelchair would not 
meet the enrollees needs versus a Group 3 power wheelchair. Our reviewer found that there is inadequate 
clinical documentation regarding why they require power tilt and recline and cannot adequately perform 
pressure relief. There is no history of skin breakdown, and the enrollee is continent of bowel and bladder and 
has intact sensation. There is no significant lower extremity spasticity that would necessitate a power elevating 
foot platform. Our physician reviewer also found that the enrollee is independent with transfers and does not 
require a power seat elevator. 
 
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 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with multiple power option (K0861) and additional items and accessories (codes E0955, E1007, 
E1012, E1028, E2300, E2311, E2313, E2323, E2363, E2377, E2605, and E2613).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service July 26, 
2023. 
 
You asked the Plan to pay for the billed code. You say that the drug was a necessary part of treatment. The 
Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
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, the CPT Code Manual definition of code J3490 is unclassified drugs. We find that CPT code J3490 
is not supported in the medical record. Code J3490 was billed for local anesthetic drug Bupivacaine. The use of 
local anesthesia is not separately billable. Based on this information, we decided that Medicare rules for 
coverage of the billed code have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code J3490 billed for date of service July 26, 2023.
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 will not be able to receive 
the care they need in a lower level of care and is stable for discharge to an LTACH. The Plan denied your 
request. The Plan says the enrollee can receive appropriate care in another setting or in the current acute care 
setting. 
 
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 in the current acute care setting as provided 
by the Plan. Documentation does not support that LTACH services are medically appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of home health services. You asked the 
Plan to pre-approve home health services. You say that continuation of home health services is medically 
necessary. You also say the enrollee lives alone and depends on their wheelchair for mobility and accessibility and due to the wound location, they cannot perform their own wound care. You say the enrollee will be in 
jeopardy of worsening wounds and hospital readmission. The Plan denied your request. The Plan says the 
services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found it is unclear 
that the enrollee is homebound, as they can attend wound clinic appointments. There are no prior home health, 
physical therapy, or occupational therapy records to show a need for ongoing skilled care in the home. The 
requested services are not shown to be 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continuation of home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement lithium ion battery charger (L7368). 
 
You asked the Plan to pre-approve a replacement lithium ion battery charger. The Plan denied your request. 
The Plan says payment of a lithium ion battery charger (L7368) is included in the approved L5856. The Plan 
also says a separate request for L7368 should be denied as unbundled.  

The Plan must follow Medicare rules. Medicare rules say that payments for items listed in Column II (such as 
code L7368) are included in the payment for each Column I code (such as code L5856). The rules also say that 
claims for Column II items billed with the provision of a Column I item will be denied as unbundling. 
 
We looked at the file and Medicare rules. Specifically, the record shows that a microprocessor control feature 
(L5856) was approved for the enrollee, which is a Column I code, and there is no separate payment for 
replacement lithium ion battery charger (L7368) because it is being billed with a powered base item. Based on 
this information, we decided that Medicare rules for coverage of a replacement lithium ion battery charger have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement lithium ion 
battery charger (L7368).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot and knee feature. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for a microprocessor knee does not meet the Medicare criteria as reasonable 
and 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the physician documentation states that the enrollee would be a K2 ambulator which conflicts with 
the prosthetist note. The physician documentation does not reveal documentation that supports that the enrollee 
requires a microprocessor knee over a mechanical knee. 
 
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 prosthetic leg with an advanced foot and knee feature.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 300 transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 300 transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 300 transportation trips (A0120).