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

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee is unable to breath at 
night without assistance and cannot use the CPAP that they have been using. The Plan denied your request. The 
Plan says a home ventilator system is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has multiple comorbidities and appears to have a non-respiratory event, given the arterial blood gas test 
provided on admission. While the enrollee does have severe chronic respiratory failure, they may benefit from 
BiPAP therapy. Also, there is no evidence of BiPAP failure or indication that a home ventilator is required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), expandable controller (E2377), and push handles (K0108 x2). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, expandable 
controller, and push handles. You say that when three or more power seating functions/actuators/motors are 
provided, one unit of E2311, one unit of E2377, and one unit of E2313 are allowed. The Plan denied your 
request. The Plan says the electronic connection, expandable controller harness, and expandable controller 
cannot be covered as they are not medically necessary to control the three approved power options through the 
joystick (drive interface). The Plan also says the push handles cannot be covered as they are 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 an electronic connection, expandable 
controller harness, expandable controller, and push handles. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
records document that the enrollee has 3 to more than 4 out of 5 right upper extremity strength and is modified 
independent with feeding and grooming thus indicating they have adequate upper extremity strength and 
function to operate the wheelchairs power options with their own switches. Our reviewer also found that the 
provided records from the treating physician in this case do not document a medical necessity for the K0108 
push handles; the vendor also does not document any allowable charge for the K0108 push handles.  
 
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, expandable controller harness, expandable controller, 
and push handles have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection (E2311), expandable controller harness (E2313), expandable controller (E2377), and 
push handles (K0108 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care and does not require 
transfer to an LTACH. 
 
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 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 is receiving appropriate inpatient care in the current acute care setting as 
offered by the Plan. The documentation provided does not support that LTACH services are medically 
appropriate at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (LAAC) (33340). 
 
You asked the Plan to pre-approve LAAC. You say that this is medically necessary. The Plan denied your 
request. The Plan says request is not medically necessary because the records show that the enrollee is not a 
suitable candidate for short term anticoagulation, due to history of multiple episodes of gastrointestinal 
bleeding. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that LAAC is covered when specific criteria are met, such as if 
the enrollee is unable to take oral anticoagulants. 
 
   
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 LAAC. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found gastrointestinal bleeding is felt to contraindicate oral anticoagulation. While there is reference 
to consideration of the LAAC, there is no documentation that short-term anticoagulation would be clinically 
permissible, as would be required following placement of the LAAC device. As such, guidelines would not 
support implantation of a LAAC in this 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 LAAC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous transcatheter closure of the left atrial appendage with endocardial implant (LAAC) 
(33340).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee will not survive if they 
do not receive the home ventilator. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS).   
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has a compensated arterial blood gas on BiPAP and shows no signs of this therapy. The enrollee would likely 
benefit from a BiPAP and should be considered a starting point given the best practice and standard 
recommendations. Also, the enrollee does not have adequate evidence to support a home ventilator given the 
data and documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Helicoll and Celera Dual skin substitutes (Q4164, 
W4259). 
 
You asked the Plan to pre-approve Helicoll and Celera Dual skin substitutes. You say that this is medically 
necessary. The Plan denied your request. The Plan says these are unproven and not medically necessary for any 
indication due to insufficient evidence of efficacy. 
 
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 Helicoll and Celera Dual skin 
substitutes. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested services are unproven and not medically 
necessary for any indication due to insufficient evidence of efficacy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Helicoll and Celera Dual skin substitutes have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Helicoll and Celera Dual skin substitutes (Q4164, W4259).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis billed for date of service May 17, 2023. You asked the Plan to pay for the billed service. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The medical records do not show that the enrollee was being 
treated for an elbow condition that would warrant an orthosis. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the elbow orthosis billed for date of service May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750), a prefabricated post and core 
(D2954), and endodontic therapy (D3330). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the requested services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2750), a prefabricated post and core (D2954), and endodontic therapy (D3330).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer smart implantable pulse generator 
(0408T). 
 
You asked the Plan to pre-approve the Optimizer smart implantable pulse generator. You say that this is 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness for the 
Optimizer smart implantable pulse generator has 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 Optimizer smart implantable pulse 
generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found cardiac contractility modulation systems remain the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. 
 
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 Optimizer smart implantable pulse generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Optimizer smart implantable pulse generator 
(0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 billed for date of service March 7, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the service is 
included in the global surgery fee. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99213-25 is not supported in the medical record. There are insufficient medical records 
to show that the evaluation and management service was separately identifiable from minor procedure codes 
11056 and 11721. Based on this information, we decided that Medicare rules for coverage of the billed service 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213-25 
billed for date of service March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of neurostimulator electrode array. 
 
You asked the Plan to pre-approve open implantation of neurostimulator electrode array. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it does not meet 
the requirements for approval. 
 
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 open implantation of neurostimulator 
electrode array. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the records do not show that the enrollee has had 50% 
or greater improvement through test stimulation as measured through voiding diaries. In addition, the records 
do not show why an open approach (64581) is necessary rather that percutaneous approach (64561) for lead placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of open implantation of neurostimulator electrode array have not been met. 
Therefore, we decided that the Plan does not have to pre-approve open implantation of neurostimulator 
electrode array.
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee has completed their full course of 
treatment in the referring hospital but does not require intensive rehabilitation. Care for the enrollee would be 
appropriately provided in a less-intensive setting.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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 inpatient rehabilitation treatment is needed to 
help the enrollee return to daily activities and regain independence. The Plan denied your request. The Plan 
says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care 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 has a history of stroke, diabetes and end stage renal disease and is living 
at home with episodes of falling. The enrollee's medical problems are stable, and there are no complex nursing 
or rehabilitation needs.  The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/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: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction device, coded E0849, billed for date of 
service June 12, 2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided. The Plan denied 
your request. The Plan says the documentation does not support the services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The file shows that the listed ordering physician denied 
ordering the device at issue. The medical records do not show that the enrollee was being treated for an active 
problem, or that a traction device was part of a treatment plan. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the cervical traction device, coded E0849, billed for date of service June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (PCD) (E0650, E0666, 
and E0673), provided on March 13, 2023, through April 4, 2023. 
 
You asked the Plan to pay for the PCD's. You say that the items were medically necessary. The Plan denied 
your request. The Plan says pneumatic compression devices are not covered by Medicare for preventative 
services. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for the pneumatic compression devices 
(PCD) (E0650, E0666, and E0673), provided on March 13, 2023, through April 4, 2023.