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

 
We decided that the Plan does not have to pre-approve a nerve stimuator (E1399). 
 
You asked the Plan to pre-approve the nerve stimuator. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of Neuromuscular electrical stimulators to 
treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, 
including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. Some 
examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, 
and hip replacement surgery. 
 
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 nerve stimuator. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found given the motor and sensory loss, it 
appears that the nerve is not intact and therefore, the request does not meet coverage criteria. 
 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 nerve stimuator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a nerve stimuator (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Livalo. 
 
You asked the Plan to pre-approve Livalo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Livalo.   
Benefits for Livalo may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0667 and E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the requested 
device is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliances (E0667 and E0656).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this item is medically needed. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee orthosis (L1852) 
 
You asked the Plan to pre-approve the knee orthosis. You say that this item is medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for a knee orthosis to be covered, knee instability 
must be documented by examination of the beneficiary and there must be an objective description of joint 
laxity. 
 
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 knee orthosis. Our reviewer says 
that this item is medically necessary. Our physician reviewer found this ambulatory Beneficiary has 
documented positive McMurrays test on the left, and lateral compartment osteoarthritis confirmed by x-ray in 
both knees. 
 
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 knee orthosis have been met. Therefore, we decided that the Plan has to pre-
approve a knee orthosis (L1852)  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation system. You say that you are 
requesting a review of the denial of coverage for the Vest system. The Plan denied your request. The Plan says 
the enrollee does not have a qualifying diagnosis and does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. 
This means that you do not have a medical condition for which a high frequency chest wall oscillation devise 
can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a 
high frequency chest wall oscillation system (E0483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that the requested CGM should be covered. 
The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires either low blood sugars or insulin use. This enrollee is, as of June 14, 2023, only taking metformin 
which should not cause low blood sugars. We are not told that the enrollee is having low blood sugars nor that 
they are on insulin. The criteria are not met. One could argue that blood glucose monitoring is not necessary in 
an enrollee that is on just Metformin with an A1c of 5.2%. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
appliances (E0656, E0668). 
 
You asked the Plan to pre-approve the pneumatic compression device (E0652) and related appliances. You say 
that this device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and related appliances (E0656, E0668).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator trial.  You asked the Plan to pre-approve a sacral nerve stimulator trial. You say that a sacral nerve stimulator trial is 
medically necessary. The Plan denied your request. The Plan says a sacral nerve stimulator trial does not meet 
the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a sacral nerve stimulator trial 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 sacral nerve stimulator trial. Our 
reviewer says that a sacral nerve stimulator trial is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee with a multi-year history of urinary frequency and mixed 
urinary incontinence, urge predominant. The enrollee uses approximately 8-9 urinary pads per day and has 
incontinence both during the day and night. The enrollee has 3-4 episodes of incontinence overnight. The 
enrollee completed 3-4 sessions of percutaneous tibial nerve stimulation in 2018 and felt that it was improving 
her symptoms and then she discontinued treatment because she relocated to another state. There is no 
documentation of failure, intolerance, or contraindication to conservative medical management 
(e.g., bladder training, pharmacotherapy). 
 
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 sacral nerve stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacral nerve stimulator trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty extra-wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy-duty extra-wide hospital bed. You say that the requested item is a 
necessity for your care. The Plan denied your request. The Plan says the requested item 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 a heavy-duty extra-wide hospital bed. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that you are unable to make it to an in-office visit, and so no weight is 
documented in the medical records. Regardless, you are still able to ambulate and get out of bed. It is unclear if 
pain or any issues would improve with the requested hospital bed for these reasons. 
 
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 heavy-duty extra-wide hospital bed have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a heavy-duty extra-wide hospital bed (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  the magnetic resonance imaging, spinal 
canal and contents (72148) provided January 28, 2023. 
 
You asked the Plan to waive the copayment for  the MRI . You say that you should not have to pay for this 
because you had to through another ordeal of having another MRI because of their negligence. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 
copay for in-network diagnostic radiology services.  
 
You have been asked to pay $225 copay for the MRI. This item/service falls within the Diagnostic testing 
benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for  the magnetic resonance 
imaging, spinal canal and contents (72148) provided January 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0172). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this item is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0172).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TissueCypher Barrett's esophagus assay (0108U) to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the genetic testing. You say that the results of your testing will impact the 
enrollee's treatment Plan. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 
the TissueCypher Barrett's esophagus assay (0108U) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Xeomin every 10 weeks. 
 
You asked the Plan to pre-approve treatment with Xeomin every 10 weeks. You say that the requested 
frequency of treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested frequency of treatment is not medically necessary. 
 
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 treatment with Xeomin every 10 weeks. 
Our reviewer says that treatment with Xeomin every 10 weeks is not medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has facial spasms and has been receiving the requested drug every twelve weeks. The record provided is insufficient to establish that the requested service is required 
more frequently than the interval enumerated in the Medicare rules.  The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment with Xeomin every 10 weeks have not been met. Therefore, we 
decided that the Plan does not have to pre-approve treatment with Xeomin every 10 weeks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon. 
 
You asked the Plan to pre-approve these services. You say that the requested surgeon has less-invasive surgical 
techniques. The Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network orthopedic surgeon.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve combination use of Opdivo, Yervoy, and Imfinzi. 
 
You asked the Plan to pre-approve Opdivo, Yervoy, and Imfinzi. You say that this combination is the best 
option for the enrollee. The Plan denied your request. The Plan says the clinical effectiveness of this 
combination has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo, Yervoy, and Imfinzi. Our 
reviewer says that the enrollee does not meet criteria for this drug combination. Our physician reviewer found 
this drug combination has not been approved by the Food & Drug Administration (FDA) for the enrollee's diagnosis. The requested combination is not supported by one of the major drug compendia or by clinical 
research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo, Yervoy, and Imfinzi have not been met. Therefore, we decided that the 
Plan does not have to pre-approve combination use of Opdivo, Yervoy, and Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 13, 2023, billed with 
evaluation and management code 99223-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99223-25 is initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 We find that CPT code 99223-25 is not supported in the medical record. Specifically, no evaluation and 
management note has been provided to verify that at a significant, separately identifiable service was 
performed.  Based on this information, we decided that Medicare rules for coverage of the practitioner services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on May 13, 2023, billed with evaluation and management code 99223-25.