Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of pacemaker pulse generator. 
 
You asked the Plan to pre-approve insertion of pacemaker pulse generator. You say that insertion of pacemaker 
pulse generator is medically necessary. The Plan denied your request. The Plan says the requested insertion of 
pacemaker pulse generator is not medically necessary and does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that insertion of pacemaker pulse generator is covered 
when the criteria listed in the Medicare rules section of this decision 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 insertion of pacemaker pulse generator. 
Our reviewer says that the requested insertion of pacemaker pulse generator is not considered medically 
necessary in this case. Our physician reviewer found that the enrollees electrocardiogram (ECG) shows a QRS 
duration of 132ms and no evidence of left bundle branch block. As such, guidelines would not support implant 
of a cardiac resynchronization therapy defibrillator (CRT-D). In summary, there is insufficient documentation 
to support the medical necessity for implantation of a CRT-D in this enrollees 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 insertion of pacemaker pulse generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion of pacemaker pulse generator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a vacuum assist suspension system. 
 
You asked the Plan to pre-approve the requested services. You say that the increased suspension and volume 
management allows greater freedom. The Plan denied your request. The Plan says the vacuum socket is 
experimental.  
 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 requested services. Our physician 
reviewer found that the use of a vacuum assisted suspension system, coded L5781, for residual limb volume 
management and moisture evacuation systems among lower extremity amputees is unproven due to insufficient 
evidence of safety and/or efficacy. The physician documentation does not support the need for the elevated 
vacuum suspension system. Therefore, the request is not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve  a vacuum assist suspension system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient T12, L1, and L2 Kyphoplasty (22513 and 
22515). 
 
You asked the Plan to pre-approve the services. You say that the enrollee would benefit from this procedure.  
The Plan denied your request. The Plan says there is no documentation of 25 percent vertebral body height 
reduction to T12, L1, or L2. The Plan states there is retropulsion noted. The Plan states there is also additional 
pathology noted on the magnetic resonance imaging (MRI): disc osteophyte complex, thecal sac effacement, 
bilateral foraminal stenosis, and facet arthropathy. The Plan states there is no documentation of acute or 
subacute fractures at L1 or L2. The Plan states the MRI notes that L1 is a chronic fracture and there is no 
documentation of a L2 fracture.  
 
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 physician reviewer 
found detailed documentation is not evident regarding worsening pain. There is no indication of a progression 
of the body height loss, greater than 25 percent vertebral body height loss, kyphotic deformity, or a severe 
impact on daily activities. Moreover, there is MRI corroboration of retropulsion at the L1 level which is also 
noted to be a chronic compression fracture. The MRI additionally corroborates other plausible causes of the 
low back pain. Therefore, the requested Kyphoplasty at T12, L1, and L2 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the outpatient T12, L1, and L2 Kyphoplasty (22513 and 22515).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says that the requested ventilator is not medically necessary.  
 
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 the home ventilator. Our physician 
reviewer found the enrollee's documentation does exhibit failure of biPAP and improved quality of life (QOL) 
and symptomatology with trilogy home ventilation. Therefore, the enrollee failed biPAP, and best practice 
would be to continue trilogy ventilator supportive therapy.  
 
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 home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve the home ventilator (E0466).  
 
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 March 27, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for office visit. You say that the assisted living facility is responsible for obtaining 
prior authorization. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and authorization was not obtained. 
 
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 March 27, 2023, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for August 15, 2023, forward as this enrollee 
was not shown to be a danger to herself or others. There were no delusions, auditory or visual hallucinations 
noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856), power seating system, tilt only (E1002), an electronic connection between wheelchair 
controller and one power seating system motor (E2310), 22nf sealed lead acid battery (E2361), retractable or 
removable mounting hardware for joystick (E1028), cushioned headrest (E0955), calf rest/pad (E0995), and 
skin protection wheelchair seat cushion (E2603).  
You asked the Plan to pre-approve a group 3 standard power wheelchair with single power option and 
additional items and accessories. The Plan denied your request. The Plan says the records do not show that the 
enrollee cannot use a cane or oh walker, a manual wheelchair or that they need these devices for activities of 
daily living. The Plan also says there is no documentation that this can be used in the enrollee's home or that 
the enrollee has been examined by a therapist to determine the needs that they require. 
 
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 group 3 standard power wheelchair 
with single power option and additional items and accessories. Our reviewer says that the enrollee does not 
meet the criteria for coverage. Our physician reviewer found the enrollee is noted as having a normal 
neurological exam. There is no record of a functional assessment. Our reviewer also found that the record does 
not indicate the enrollee requires a power wheelchair to accomplish MRADLs. 
 
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 with single power option 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 single power option (K0856), power seating system, tilt only (E1002), 
an electronic connection between wheelchair controller and one power seating system motor (E2310), 22nf 
sealed lead acid battery (E2361), retractable or removable mounting hardware for joystick (E1028), cushioned 
headrest (E0955), calf rest/pad (E0995), and skin protection wheelchair seat cushion (E2603).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve remote monitoring services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve remote monitoring services to be provided by an OON provider. You say 
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services are neither emergent nor urgent to seek OON care. The Plan says there are in-network 
providers available to the enrollee that can provide the services requested. 
 
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 
remote monitoring services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need the requested 
portable oxygen concentrator due to a foot amputation. You say that you have a cane and a walker but cannot 
walk around with both the tank and your cane.  The Plan denied your request. The Plan says the enrollee has 
not tried and failed portable B or liquid oxygen tanks.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found a portable oxygen 
concentrator is not medically necessary. This enrollee has chronic obstructive pulmonary disease (COPD.)  The 
enrollee uses a walker and cane and is unable to manage the portable tank.  There is no documentation that the 
Saturation of Peripheral Oxygen (SpO2) can be maintained above 91% using an oxygen conserving device with 
a flow rate of 1 to 4 liters per minute (L/min.) 
 
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 portable oxygen concentrator have not been met.  Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve balloon dilation of the eustachian tube (69706). 
 
You asked the Plan to pre-approve the surgical service. You say that your hearing aid doctor and ear, nose and 
throat specialist (ENT) agree that this service would improve your hearing.  The Plan denied your request. The 
Plan says this procedure has not been medically proven to be effective and, therefore, is considered not 
medically necessary in the treatment of chronic eustachian tube dysfunction (ETD). 
 
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 surgical service. Our reviewer says 
that the requested surgical service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation is not sufficient to support persistent Eustachian tube 
dysfunction despite medical management. Therefore, the reviewer found that the requested surgical service 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 the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve balloon dilation of the eustachian tube (69706).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with multiple 
power options (K0842) and additional items and accessories (codes E1012, E1028, E0955, E2311, E2313, 
E2377, E1007, E2361 x2, and E2603). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says this request is not medically necessary. The Plan also says the 
group 2 power wheelchair to include power tilt/recline and power elevating leg rests exceeds the enrollee's 
needs for mobility and positioning. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 multiple power option power wheelchair 
(PWC) (K0841, K0842, K0843) is covered if certain criteria are met. Medicare rules also say 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 2 standard power wheelchair 
and additional items and accessories. Our physician reviewer found the enrollee has medical conditions with 
functional deficits. The documentation does not indicate that the enrollee has any pressure injuries, requires 
intermittent catheterization of the bladder, or has spasticity that would necessitate power tilt or recline. Our 
reviewer found that although the members condition may meet criteria for a power wheelchair, the criteria for 
this specifically requested power wheelchair with multiple power options including power tilt and recline are 
not met. 
 
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 additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair with multiple power options (K0842) and additional items and accessories (codes E1012, E1028, 
E0955, E2311, E2313, E2377, E1007, E2361 x2, and E2603).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a loop recorder implant. 
 
You asked the Plan to pre-approve a loop recorder implant. You say that a loop recorder implant is medically 
necessary. The Plan denied your request. The Plan says the requested loop recorder implant does not meet the 
Medicare NCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that a loop recorder implant is covered when the criteria 
listed in the Medicare rules section of this decision 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 loop recorder implant. Our reviewer 
says that a loop recorder implant is not considered medically necessary in this case. Our physician reviewer 
found that there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR 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 a loop recorder implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a loop recorder implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient was taken to the hospital a few 
days ago, and the concern is he will be readmitted without this device. The Plan denied your request. The Plan 
says the patient's needs can be met with a bilevel positive airway pressure (BiPAP) device with average 
volume-assured pressure support (AVAPS).  
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has severe COPD, 
severe obesity, and obstructive sleep apnea.  The patient has a BiPAP-ST device at home, set at 16/12.  Clinical 
notes indicate the patient is using it every night, but no compliance download data are provided.  The patient 
recently had an arterial blood gas done during a visit to the emergency room for dyspnea, showing a pH of 7.36 
and a PaCO2 of 58, on oxygen.  There is no evidence that the patient has been tried on BiPAP with AVAPS as 
an outpatient.  The order for the ventilator is for use in the AVAPS mode.  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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.