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

 
We decided that the Plan does not have to pre-approve a transfer bench for tub or toilet (E0247). 
 
You asked the Plan to pre-approve a transfer bench for tub or toilet. You say that the item should be covered. 
The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 transfer bench for tub or toilet 
(E0247).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myopro Orthosis (L8702). 
 
You asked the Plan to pre-approve a Myopro Orthosis. The Plan denied your request. The Plan says the 
requested device 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 Myopro Orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this patient's condition or in widespread use for this patient's condition based on scientific evidence. 
Our reviewer found that there is insufficient evidence in the literature that the MyoPro Orthosis will improve 
the long-term outcomes for this patient.  Our physician reviewer also found that there is insufficient evidence in 
the literature that this device will increase participation in bimanual activities. 
 
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 Myopro Orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Myopro Orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 23, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was the only provider available to see this 
patient, and it was medically necessary for them to be seen. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the MyoPro is supported as an appropriate 
intervention and is reasonably and medically necessary as recognized by medical communities and key opinion 
leaders in rehabilitation. The Plan denied your request. The Plan says coverage cannot be approved for the 
MyoPro because there is not enough medical proof that shows the safety and/or success of MyoPro. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this patient's condition or in widespread use for this patient's condition based on scientific evidence. 
Our reviewer found that there is insufficient evidence in the literature that the MyoPro Orthosis will improve 
the long-term outcomes for this patient. Our physician reviewer also found that there is insufficient evidence in 
the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76705 billed for date of service March 1, 2023. 
 
You asked the Plan to pay for procedure code 76705. You say that this service was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says that diagnosis codes R17 and K76.89 should 
not be reported together. 
 
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, we were not able to verify any Excludes note between diagnosis 
codes R17 and K76.89. The Plan has not provided a supported reason for denial in this case. Therefore, we 
decided that the Plan has to pay for procedure code 76705 billed for date of service March 1, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 11, 2022, to 
August 12, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says that an inpatient admission was not medically 
necessary.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the time of the enrollee's admission to the hospital the admitting physician reasonably 
expected that the enrollee's necessary hospital care would span two midnights. The enrollee presented with 
rapid atrial fibrillation and congestive heart failure, a clinical situation that is unstable and challenging to 
manage under the best of circumstances. Deterioration prior to improvement was a possibility and the enrollee 
responded well to management and was able be discharged after only two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 11, 2022, to August 12, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 60 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 60 routine transportation trips. You say that the enrollee needs 
transportation for medical appointments. The Plan denied your request. The Plan says the enrollee has utilized 
the maximum number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 60 routine transportation trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omalizumab injection to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an Omalizumab injection. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services can be provided by a network provider. 
 
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 
an Omalizumab injection to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at T10-T12. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that because of acute fractures and persistence of 
pain despite immobilization, this procedure is still recommended. The Plan denied your request. The Plan says 
the enrollee has not met the requirements for this procedure. 
 
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 kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is bone retropulsion on the magnetic resonance imaging (MRI) which is a 
contraindication to kyphoplasty. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at T10-T12.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) device. 
 
You asked the Plan to pre-approve an ILR device. You say that you want to appeal this denial. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate a history of atrial fibrillation, nor were there any significant cardiac arrhythmias noted on the 
electrocardiogram (ECG) monitoring. Therefore, the reviewer fund that the insertion of an ILR is not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR) device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent. 
 
You asked the Plan to pre-approve the medication. You say that the request 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 Praluent.  Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service March 2, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service March 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x7). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation does not specify any acute medical concerns, change in medications, or change in plan of care. 
The records do not show that 7 home health skilled nursing visits are required to effectively provide treatment, 
care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance 
program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x7).
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 has tried and failed on a 
BiPAP. 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 COPD, interstitial lung disease, and chronic pain treated with daily opioids. However, there are no 
pulmonary function tests to confirm airway obstruction and asses the severity. Also, there is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. Additionally, the records do not show that a BiPAP with 
AVAPS during sleep as an outpatient has been tried and failed. Therefore, Medicare does not cover a home 
ventilator when used at settings that can be provided with a 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 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: 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 enrollee had major back surgery and isn't 
progressing, physical and occupational therapy isn't working. Home Health is not an option and its going to 
require 24 hour supervision until making improvements necessary to regain independence. The Plan denied 
your request. The Plan says the enrollee's records do not show rehabilitation needs are complex. The Plan says 
that the services needed may be provided safely in a lower level of care.  
 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.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee's disease requires a non-
invasive system with volume augmented ventilation and the ability to records a respiratory rate to help avoid 
hospital re-admission and help control the enrollee's condition. 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 severe obesity, obesity hypoventilation syndrome and obstructive sleep apnea. The enrollee is a lifelong 
smoker with asthma, however recent clinical notes indicates that it is well controlled. There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. Also, the records do not show that the enrollee has tried 
and failed a BiPAP with AVAPS during sleep as an outpatient. Therefore, a home ventilator 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on April 27, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the sample was sent to the laboratory for 
confirmation. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on April 27, 2023.