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

 
We decided that the Plan does not have to pre-approve nine (9) month use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9-month use of a ventilator. You say that the enrollee's medical condition 
would improve with more than 3 months of the home ventilator. The Plan denied your request. The Plan says 
the request for continued use of a ventilator is not medically reasonable and 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. 
 
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 9-month use of a ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has COPD 
and has had a home ventilator since July 2020. A compliance report covering February 22, 2023, to May 30, 
2023, shows the enrollee is using the device at least 4 hours/day for 57% of days, in the average volume-
assured pressure support-automated expiratory (AVAPS-AE) mode. There are no pulmonary function tests to 
assess the severity of the COPD. There is no arterial blood gas (ABG) done while stable to document chronic 
carbon dioxide (CO2) retention. If that is present, the enrollee may benefit from bilevel positive airway 
pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an outpatient. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP.  The 
enrollee is not using the device enough for full benefit. The plan has approved the current device for 3 months 
to allow time for transition to 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 9-month use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) month use of a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair (E1399). 
 
You asked the Plan to pre-approve a recliner chair. You say that this item should be covered. The Plan denied 
your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner chair (E1399).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99222 and 99232. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 99232.  
 
You asked the Plan to pay for practitioner services provided on February 5, 2023, billed with procedure code 
99232. You say that the claim is billed correctly and should be paid. The Plan says that documentation does not 
support the billed code. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99222 and 99232.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99222 and 99232.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99232. 
 
The Plan follows Medicare rules. Medicare rules say that procedures should be reported with the Current 
Procedural Terminology (CPT) code that describes the services performed. 
 
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 described by procedure code(s) 99232 have not been met. No 
medical records have been provided for services provided on February 5, 2023 to support billed service. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
99232. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 You asked the Plan to pre-approve Zilretta. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Zilretta. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plan's required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high-dose rate electronic brachytherapy. 
 
You asked the Plan to pre-approve brachytherapy. You say that brachytherapy is the best option because it 
spares healthy nearby tissue. The Plan denied your request. The Plan says that the request 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 brachytherapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no compelling reasons offered for why brachytherapy would be needed over more 
standard approaches of radiation delivery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of brachytherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve high-dose rate electronic brachytherapy.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 24, 2022, to 
December 23, 2022. 
 You asked the Plan to pay for the home health services. You say that your software couldn't bill the required 
NOA at the time of admission. The Plan denied your request. The Plan says the NOA was not received timely. 
As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 26, 2022. The NOA was not received by the Plan until April 27, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from November 24, 2022, to December 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan must follow Medicare rules and cannot approve this request. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 the item. Our reviewer says that the 
requested mechanism is not medically reasonable or necessary. Our physician reviewer found that in this case, the documentation doesnt indicate that you have severe neuromuscular disease or that you are incapable of 
standing up from a regular armchair or any chair in the home. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a seat lift mechanism.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on April 
20, 2023. 
 
You asked the Plan to pay for the dental service. You say that the new dental x-rays were necessary because 
you went to a new dentist. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the adjunctive pre-diagnostic test is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431) provided on April 20, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you have cerebral palsy which is causing you not to 
be able to walk or care for yourself. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic BMP Infuse allograft (20930, 27280). 
 
You asked the Plan to pre-approve Medtronic BMP Infuse allograft. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Medtronic BMP Infuse allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found BMP is not FDA approved for SI joint or lumbar fusion. It is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Medtronic BMP Infuse allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Medtronic BMP Infuse allograft (20930, 27280).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that a BiPAP device is not available with the requested 
setting. The Plan denied your request. The Plan says the enrollee's needs can be met with a BiPAP device.  
 
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 physician reviewer 
found that the enrollee has severe COPD and was recently hospitalized with an exacerbation.   Arterial blood gas (ABG) was consistent with severe acute on chronic hypercarbic respiratory failure.  
Pulmonary function tests showed a forced expiratory volume (FEV1) of 30% of predicted with an obstructive 
pattern. The ventilator is to be used in a mode, which can be provided with BiPAP.  Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP. There is no evidence that BiPAP has 
been tried and failed as an outpatient. 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), a 
cone beam (D0364), the pulp vitality test (D0460), and the core buildup (D2950) for tooth #5 provided on 
March 14, 2023, and March 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the claim reprocessed and paid. 
The Plan denied your request. The Plan says your benefit for the intraoral radiographic images has already been 
exhausted. Also, the cone beam, the pulp vitality test, and the core buildup are not covered by the 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, certain limitations apply. The record 
shows the Plan paid for the intraoral radiographic image (D0220) on March 13, 2023; therefore, your benefit 
for the intraoral radiographic images was exhausted on the date of service of March 13, 2023. The cone beam, 
the pulp vitality test, and the core buildup are not covered under the Plan's dental benefit. Therefore, we 
decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), a cone 
beam (D0364), the pulp vitality test (D0460), and the core buildup (D2950) for tooth #5 provided on March 14, 
2023, and March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foam propulsion tires, any size, each (E2218). 
 
You asked the Plan to pre-approve the foam tires. You say that the enrollee is an ideal candidate for a ultra-
lightweight manual wheelchair. The Plan denied your request. The Plan says foam tires are convenient for 
outdoor use but not medically needed in the home. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. In this case the foam tires are ideal for outdoor use and not medically 
necessary in the home. These items or services do not meet the coverage criteria. Based on this information, we 
decided that Medicare rules for coverage of the foam tires have not been met. Therefore, we decided that the 
Plan does not have to pre-approve foam propulsion tires, any size, each (E2218).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VivAer procedure (30801, 30469, 31231, 30117). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that Original Medicare covers nasal airway 
remodeling using the procedure codes that are being requested. You also say that this should be covered. The 
Plan denied your request. The Plan says the clinical value and effectiveness of the VivAer procedure in the 
setting of nasal turbinate hypertrophy have not been demonstrated in the peer-reviewed literature. 
 
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 VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the clinical documentation is insufficient to demonstrate that the VivAer 
procedure is medically reasonable and necessary for the enrollee in this case.   
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve VivAer procedure (30801, 30469, 31231, 30117).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (22585 x2, 22630, 22558) and insertion of 
interbody biomechanical device (22853). 
 
You asked the Plan to pre-approve arthrodesis and insertion of interbody biomechanical device. You say that 
this is medically necessary. The Plan denied your request. The Plan says this 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 arthrodesis and insertion of interbody 
biomechanical device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no documentation of an unstable 
spine. Physical exam does not correlate with imaging showing neurological compression and deficit. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis and insertion of interbody biomechanical device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve arthrodesis (22585 x2, 22630, 22558) and 
insertion of interbody biomechanical device (22853).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronic acid injection. 
 
You asked the Plan to pre-approve hyaluronic acid injection. You say that this is medically necessary. The Plan 
denied your request. The Plan says per both guidelines, the request for hyaluronic acid injection for 
temporomandibular joint is considered experimental, investigational, and/or unproven. Additional study is 
recommended to determine effectiveness of this injection. 
 
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 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 hyaluronic acid injection. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the review has determined that 
the documentation does not support that the hyaluronic acid injection is medically reasonable or necessary for 
the enrollee. The documentation does not support that the hyaluronic acid injection is safe and effective for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyaluronic acid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyaluronic acid injection.