Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a segmental pneumatic compressor (E0652) and 
segmental gradient pressure pneumatic appliance, full leg (E0671) from an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve  a segmental pneumatic compressor and segmental gradient pressure 
pneumatic appliance, full leg from an OON provider. You say that the design of their product is not available 
with any other pump and is only available out-of-network.  The Plan denied your request. The Plan says their 
participating provider provides a comparable product for CPT codes E0652 and E0671. The Plan says that 
there is no evidence of an urgent or emergent condition, for which the enrollee cannot use or try a comparable 
product from a participating provider.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 segmental pneumatic compressor and 
segmental gradient pressure pneumatic appliance, full leg from an OON provider. Our reviewer says that the 
criteria for coverage of OON care have not been met.  Our physician reviewer found the Plan denial is 
medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through 
referral to their network provider. There is nothing unique about the enrollee's condition that would make it 
medically necessary to use the OON provider. The documentation provided does not support that the self-
learning fill-to-fit technology that automatically adjusts to limb size during each therapy session is medically 
reasonable and necessary, as opposed to the device offered in-network.  
 
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 segmental pneumatic compressor and segmental gradient pressure pneumatic 
appliance, full leg from an OON provider have not been met. Therefore, we decided that the Plan does not have 
to pre-approve  a segmental pneumatic compressor (E0652) and segmental gradient pressure pneumatic 
appliance, full leg (E0671) from 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 lives alone with a decrease in mobility 
which impairs their activities of daily living. The Plan denied your request. The Plan says an IRF admissions is 
not medically necessary, and the enrollee's needs can be met at an alternate level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care. The Plan denied your 
request. The Plan says the denial of IRF care is correct. 
 
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 the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1852), suspension sleeve (L2397), and back 
brace (L0457) provided on January 25, 2023.  
 
You asked the Plan to pay for the braces. You say that there was a visit with the ordering provider, and the 
items furnished should be paid. The Plan denied your request. The Plan says this equipment was provided after 
a phone call to the enrollee in which provision of the braces was offered.  
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the braces have not 
been met. Therefore, we decided that the Plan does not have to pay for the knee brace (L1852), suspension 
sleeve (L2397), and back brace (L0457) provided on January 25, 2023.
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. 
 
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 the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
The elements of the coverage criteria are not satisfied. The requested service cannot be 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a manual wheelchair. 
 
You asked the Plan to pre-approve manual wheelchair. You say that you need both the power wheelchair and 
manual wheelchair. The Plan denied your request. The Plan says since you already have a functioning power 
wheelchair a second wheelchair is duplicative, so repairs are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. A power wheelchair serves the same purpose as manual 
wheelchair. Therefore, we decided that the Plan does not have to pre-approve repairs to a manual wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle 3 continuous glucose monitor. 
 
You asked the Plan to pre-approve Freestyle 3. You say that you are appealing this denial. The Plan denied 
your request. The Plan says a Freestyle Libre 3 is not covered by Medicare at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle 3 continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy provided on January 6, 2023. 
 
You asked the Plan to pay for physical therapy. You say that the enrollee was referred for physical therapy by 
the dentist. The Plan denied your request. The Plan says that the member's plan does not cover charges for 
treatment of temporomandibular joint dysfunction (TMJ) other than by an open cutting operation. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for physical therapy provided on 
January 6, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 18, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 18, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation treatment (PBRT) with 28 
fractions (77523). 
 
You asked the Plan to pre-approve PBRT with 28 fractions. You say that PBRT is better than intensity 
modulated radiation therapy which is the current standard of care. The Plan denied your request. The Plan says 
the information received does not meet criteria because the requested radiation treatment is not the standard of 
care for malignant neoplasm of the prostate. 
 
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 PBRT with 28 fractions. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient prospective, long-term clinical data available to determine 
whether or not proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent to external 
beam radiation therapy, IMRT, or brachytherapy with regards to safety and efficacy. Recent data shows no 
significant differences in late (years one, two, and three) enrollee-reported toxicity outcomes between proton 
beam therapy and IMRT. The most recent AUA and NCCN guidelines state that PBT offers no clinical 
advantage over other forms of definitive treatment. According to NCCN and ASTRO guidelines proton beam 
therapy may be offered to enrollees enrolled in an IRB approved prospective clinical trial or multi-institutional 
registry that adheres to Medicare requirements for CED. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT with 28 fractions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation treatment (PBRT) with 28 fractions (77523).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 8, 2023, billed with 
code 61781-AS. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that a payment restriction for assistants at surgery 
applies to this procedure. 
 The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 61781. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 imaging services provided. Our reviewer 
says that documentation does not support the billed code. Our physician reviewer found that although provided 
medical records document that an assistant was present for the procedure on February 8, 2023, the records do 
not specifically support that the assistant was medical necessary as required by the Centers for Medicare & 
Medicaid Services (CMS) Medicare physician fee schedule database.  
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on February 8, 2023, billed with code 61781-AS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an enclosed frame walker described by code E0144. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an enclosed frame walker is denied as not 
medically necessary. 
 
We looked at the file and Medicare rules. The item at issue is an enclosed frame walker described by code 
E0144. This item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does 
not have to pre-approve an enclosed frame walker described by code E0144.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided from February 25, 2022, to April 
30, 2022. 
 
You asked the Plan to pay for surgical services. You say that these services should be covered The Plan denied 
your request. The Plan says these services were received from a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for surgical 
services provided from February 25, 2022, to April 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a permanent leadless pacemaker (33274). 
 
You asked the Plan to pre-approve placement of a permanent leadless pacemaker. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when 
furnished outside of a Medicare-approved CED study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of placement of a permanent leadless pacemaker have not been met. Specifically, there is no indication in the case record that the enrollee is participating in a Medicare-approved CED study. Therefore, 
we decided that the Plan does not have to pre-approve placement of a permanent leadless pacemaker (33274).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Freestyle Libre 14 continuous glucose monitor (CGM) system. 
 
You asked the Plan to pre-approve the CGM system. The Plan denied your request. The Plan says that the 
coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the coverage criteria are not met in this case. However, the 
Plan has not provided medical records used to make its decision. A requested for medical records was faxed to 
the Plan on June 26, 2023, and a response was not received. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pre-approve the Freestyle Libre 14 
continuous glucose monitor (CGM) system.  
 
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.