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

 
We decided that the Plan has to pre-approve the custom platform and extra-large platform (K0108). 
 
You asked the Plan to pre-approve the custom platform and extra-large platform. You say that the item is 
medically necessary. The Plan denied your request. The Plan says that the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that adjustable angle footplates coded K0040 
(ADJUSTABLE ANGLE FOOTPLATE, EACH) are separately payable when provided with leg rests coded as 
E1012. 
 
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 custom platform and extra-large 
platform. Our reviewer says that the item is medically necessary. Our physician reviewer found the enrollee is 
non-ambulatory and requires a power wheelchair for mobility and performing her basic daily activities. She 
cannot perform pressure relief independently due to upper extremity weakness and requires a power wheelchair 
with power tilt and recline for adequate pressure relief and positioning. She currently has a coccygeal pressure 
wound. She requires power elevating leg rests for positioning of her lower extremities and lower extremity 
spasticity. The complexity of her seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. She requires an angle adjustable footplate to support her right lower extremity. 
 
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 custom platform and extra-large platform have not been met. Therefore, we 
decided that the Plan has to pre-approve the custom platform and extra-large platform (K0108).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 30, 2022 to 
July 25, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that you submit claims electronically 
through a third-party vendor that had a system issue beyond your control. The Plan denied your request. The 
Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 30, 2022 to July 25, 
2022.
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 these services are medically necessary. The Plan 
denied your request. The Plan says the services you need can be provided safely in other settings. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. Medically necessary care can be 
provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult disposable diapers. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has declined medication 
and is needing up to five adult diapers per day for ongoing use. The Plan denied your request. The Plan says 
diapers are included in supplies for incontinence that are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve adult disposable diapers.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. The Plan denied your request. The Plan says  
the radiofrequency ablation 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 the radiofrequency ablation. Our 
reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found that the 
enrollee only had one set of blocks that achieved 80% pain relief. Therefore, the request does not meet the LCD 
criteria and is not medically reasonable and 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate. 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that the enrollee has chronic back pain. 
The Plan denied your request. The Plan says medical studies have not proven that the use of this product during 
spinal surgery is better than standard allograft product. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support 
the use of bone marrow aspirate for this enrollee's medical condition as discussed above. No compelling 
rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE) (37243). 
 
You asked the Plan to pre-approve a PAE. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this service is considered experimental and therefore is not covered. 
 
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 PAE. Our reviewer says that the 
requested PAE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign 
prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. 
Therefore, the reviewer found that the requested PAE 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 PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve prostate artery embolization (PAE) (37243).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and cannot be safely discharged home 
and require rehabilitation in an IRF setting. 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair and accessories (K0005, 
E0951, E0971, E0973, E2211, E2609, E2617, K0038, K0040, K0108). 
 
You asked the Plan to pre-approve an ultralightweight wheelchair and accessories. You say that the enrollee 
needs the requested wheelchair. The Plan denied your request. The Plan says the wheelchair must be for use in 
the enrollee's home, not a hospital or nursing home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that an ultralightweight wheelchair and accessories is being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve an ultralightweight wheelchair and 
accessories (K0005, E0951, E0971, E0973, E2211, E2609, E2617, K0038, K0040, K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says saphenous reflux has not been successfully eliminated, and there are reported 
tributary veins which measure less than 4mm in diameter. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the coverage criteria require that the symptoms and ulceration be due to the veins planned 
for treatment. In this case, the enrollee is documented in multiple instances in the medical record to have 
peripheral artery disease (PAD) including documentation of severe PAD. It is not possible to attribute the 
enrollees nonhealing ulcer to venous insufficiency without a satisfactory assessment of lower extremity 
arterial perfusion. It is not possible to confirm the appropriateness/medical necessity of venous treatments 
without a satisfactory assessment of lower extremity arterial perfusion. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says there is no documentation to support that the enrollee is 
enrolled in an appropriate study or registry. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Leqembi.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6550 billed for date of service March 13, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation validates the need for 
additional dressings.  The Plan denied your request. The Plan says the units were billed in excess. 
 
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 A6550 is wound care set, for negative pressure wound 
therapy electrical pump, includes all supplies and accessories. We asked our physician 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 billed services. Our reviewer found that there was no specific clinical rationale for the additional 
services. The review has determined that the records did not show the additional units provided on March 13, 
2023, were medically necessary beyond what was provided on Feb 23, 2023. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code A6550 billed for date of service March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intravascular ultrasound (procedure code 37253) rendered 
on April 5, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 37253 is "Intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 37252 would appear to 
reasonably cover the intravascular ultrasound (IVUS) that was performed. The entire IVUS circuit is one vessel 
with respect to IVUS imaging. 
 
We looked at this coder'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 pay for an intravascular ultrasound (procedure code 37253) rendered on April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on September 
06, 2022, to September 07, 2022. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
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 an office visit and 
related services provided on September 06, 2022, to September 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on February 
11, 2023. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says this testing is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on February 11, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 rendered on April 27, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 76937-58, 26 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure for the port 
placement done 4/27/23 did not mention the use of ultrasound guidance of the port placement.  Without 
specifically describing the use of ultrasound for the identification and guidance for the port placement the CPT 
76837 remains undocumented and must be denied. 
 We looked at this coder'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 pay for procedure code 76937 rendered on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on March 03, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 a home visit evaluation 
provided on March 03, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #21 (D2751). 
 
You asked the Plan to pre-approve a crown. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that the coverage criteria has not been 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 did not provide clear, readable dental x-rays or other documentation to 
help determine if the denial for a crown was correct. Therefore, we decided that the Plan has to pre-approve a 
crown on tooth #21 (D2751).  
 
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.