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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the records do not show documentation that the 
enrollee has lymphedema in an extremity or has lymphedema extending onto the chest, trunk and/or abdomen. 
 
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 records does not show that the enrollee has 
lymphedema in an extremity or has lymphedema extending onto the chest, trunk and/or abdomen. Therefore, 
we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0657).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revision of upper eyelid (15823). 
 
You asked the Plan to pre-approve the revision of upper eyelid. You say that the upper eyelid revision is not 
medically necessary. The Plan denied your request. The Plan says the service is 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 revision of upper eyelid. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee complains of seeing shadow of their lids. However, the marginal 
reflex distance is noted to be four millimeters in both eyes.  Additionally, the visual field testing does not 
demonstrate a 12 degree or 24% improvement with taping. 
 
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 revision of upper eyelid have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the revision of upper eyelid (15823).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided on May 25, 2023. 
 
  You asked the Plan to pay for the inpatient services. You say that the Plan has inappropriately denied this claim 
stating the inpatient services provided at the non-contracted facility were not authorized. You also say that the 
inpatient stay was medically necessary at the acute level of care. The Plan denied your request. The Plan says 
this request is not medically necessary because the medical record does not support the expectation of a need 
for more than an ambulatory stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that 
the documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record did not show that at the time of inpatient admission it was reasonable for the 
admitting physician to expect that the patient's necessary hospital care (including earlier emergency department 
and/or observation care) would span two midnights with supporting documentation of the patients history and 
comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient services provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99204 billed for date of service May 22, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says that the billed code is 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.  
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
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 the enrollee 
underwent a new patient evaluation for pain in multiple joints. An appropriate history and physical are 
documented.  Imaging was obtained and reviewed. A discussion regarding the diagnoses and treatments 
occurred. Educational materials were provided, and additional imaging was ordered. The documentation 
supports medical decision making of moderate complexity. 
 
We looked at this physicians review, the file, and Medicare rules. This is an either/or situation, where either 
the history/exam and complexity of the decision making must be documented, or the time spent can be used to 
select the code. Based on this information, we decided that Medicare rules for coverage of the billed services 
have been met. Therefore, we decided that the Plan has to pay for procedure code 99204 billed for date of 
service May 22, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (22558, 22612, 22585, 22614), allograft 
(20930), insertion of interbody biomechanical device (22853), posterior segmental instrumentation (22842), 
and stereotactic computer-assisted navigational procedure (61783). 
 
You asked the Plan to pre-approve arthrodesis, allograft, insertion of interbody biomechanical device, posterior 
segmental instrumentation, and stereotactic computer-assisted navigational procedure. 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, allograft, insertion of 
interbody biomechanical device, posterior segmental instrumentation, and stereotactic computer-assisted 
navigational procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident 
regarding recent objective examination to corroborate ongoing symptoms and findings. There is no indication 
there has been ongoing conservative care measures since the last documented exam on May 2, 2023. Moreover, 
dynamic flexion/extension films are not provided in order to potentially assess the amount of movement 
(instability) at the requested surgical levels. Detailed documentation is not evident regarding potential 
impending/inevitable temporary intra-operative instability. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale 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 arthrodesis, allograft, insertion of interbody biomechanical device, posterior 
segmental instrumentation, and stereotactic computer-assisted navigational procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve arthrodesis (22558, 22612, 22585, 22614), 
allograft (20930), insertion of interbody biomechanical device (22853), posterior segmental instrumentation 
(22842), and stereotactic computer-assisted navigational procedure (61783).
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 the requested SNF services are necessary because 
you are unable to perform your daily living activities and you are ambulating with the assistance of a walker. 
You also say your provider advised you not to bend, lift, or twist. The Plan denied your request. The Plan says 
admission to a SNF if 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 and/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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keppra. 
 
You asked the Plan to pre-approve Keppra. You say that the medication is medically necessary. 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 Keppra.  Benefits for Keppra 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this care has been proven to reduce the 
return to hospitalization. The Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a stable medical condition without any apparent needs that could 
only be met in a LTACH. The enrollee's needs could be met in a setting other than LTACH. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the 
enrollee's care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to regain their strength and stability to return to baseline. The Plan denied your request. The Plan says the 
enrollee's needs can be met in an alternate setting such as a skilled nursing facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that when one power seating 
function/actuator/motor is provided on a power wheelchair, one unit of E2311 is allowed. The Plan denied your 
request. The Plan says that although two power features are requested for this wheelchair (tilt and elevating leg 
rests), there is not a medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 an electronic connection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is functionally non-ambulatory and requires a power wheelchair for 
mobility and performing their basic daily activities. The patient cannot perform pressure relief independently 
due to upper extremity weakness and requires a power wheelchair with power tilt for adequate pressure relief 
and positioning. The patient currently has a gluteal pressure wound. Our reviewer found that the patient 
requires power elevating leg rests for positioning of their lower extremities and lower extremity edema. The 
complexity of their seating and positioning needs necessitates a more complex group 3 power wheelchair base. 
The electronic connection is necessary to operate the group 3 power wheelchair base and the power options via 
a joystick. Our physician reviewer also found that it is required to operate the power options on a group 3 
power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection (E2311).  
 
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 the wheelchair repairs. 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the cost of requested repairs appears to exceed the cost of replacement 
of the wheelchair.  
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair repairs have not been met. Therefore, we decided that the Plan does not have to pre-
approve the wheelchair repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 6, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the medication is medically necessary. 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 Gemtesa.  Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.