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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has been admitted to the 
hospital at least 3 times since the first of the year for acute respiratory failure and she needs the ventilator to 
prevent readmission to the hospital or worse. The Plan denied your request. The Plan says the provider has 
prescribed a ventilator to help the enrollee breath at various times of the day (night and day) because of her 
lung disease. Medicare does not cover ventilators used in this way. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the 
Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and necessary." The LCD 
requires: "There must be enough detailed information in the medical record to justify the treatment selected." 
Provided records in this case do not provide adequate detailed information to meet Medicare criteria for 
coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-ray (D0210, 
D0150) provided on December 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. The intraoral x-rays denied correctly as they do not fall within your dental 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 27, 2020. 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation and intraoral x-ray (D0210, D0150) provided on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve injections. You say that you are requesting reconsideration for the denied 
services. The Plan denied your request. The Plan says the request is not medically necessary. The Plan did not 
receive any of the enrollee's images showing the source of her pain. Additionally, the Plan did not get any notes 
that the enrollee completed 4 weeks of non-surgical treatments. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the enrollee has low back pain. She is taking Tylenol and Ibuprofen for pain. There is no 
imaging submitted for review.  There is no documentation of what conservative therapies the enrollee has tried 
and failed. The request is deemed 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral Gel-One injections. 
 You asked the Plan to pre-approve Gel-One. You say that you are in pain. You also say that you need this. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Euflexxa, 
Durolane, Supartz-FX, and Gelsyn-3.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Euflexxa, Durolane, Supartz-FX, and Gelsyn-
3. The reviewer found that there is no documentation provided indicating that the plans required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the 
step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve bilateral Gel-One injections.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing provided on January 20, 2023. 
 
You asked the Plan to pay for the SelectMDx testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says that this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for molecular diagnostic tests, such as the test at 
issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the DEX Diagnostics Exchanges shows that this testing is 
listed as covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the 
SelectMDx testing have been met. Therefore, we decided that the Plan has to pay for the SelectMDx testing 
provided on January 20, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277) and a 
non-segmental pneumatic appliance for use with pneumatic compressor, full leg (E0660). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress and a non-segmental pneumatic 
appliance. You say that you have damage in the cervix, thoracic and lumbar. You have two nails pointing to 
your spine and your tail bone is not straight. You say you have bulging and titanium discs. You need this 
mattress to help with your extreme pain. The Plan denied your request. The Plan says the records received from 
your doctor do not support the need for this service. 
 
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 powered pressure-reducing air 
mattress and a non-segmental pneumatic appliance. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case.  Our physician reviewer found provided records in 
this case do not document stage 2,3 or 4 pressure ulcers or history of skin flap surgery as required by the Local 
Coverage Article Pressure Reducing Support Surfaces - Group 2 - Policy Article A52490 and Local Coverage 
Determination (LCD) Pressure Reducing Support Surfaces - Group 2 L33642 for coverage of the air mattress. 
Records do not document the diagnosis of lymphedema as required by the Local Coverage Determination 
(LCD) Pneumatic Compression Devices L33829 for coverage of the pneumatic appliance. 
 
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 powered pressure-reducing air mattress and a non-segmental pneumatic 
appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered 
pressure-reducing air mattress (E0277) and a non-segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0660).
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 have been in the hospital and the doctor wants 
rehabilitation due to living by yourself and no strength or mobility currently. The Plan denied your request. The 
Plan says your records do not show that you have complex rehabilitation needs that require frequent evaluation 
by a rehabilitation doctor. 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 your 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for therapy services (97110, 97112 and 97168) provided from November 
1, 2022, through November 3, 2022. 
 
You asked the Plan to pay for therapy services. You say that these services were medically necessary and are 
supported in the medical records provided. The Plan denied your request. The Plan says that this claim should 
be submitted with the KY modifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the KY modifier is typically used with durable medical equipment, 
prosthetics, orthotics and supplies (DMEPOS) codes. The Plan has not clearly explained why this modifier 
would be appropriate to use with this claim, nor has the Plan provided a relevant citation and documentation to 
support their argument. Therefore, we decided that the Plan has to pay for therapy services (97110, 97112 and 
97168) provided from November 1, 2022, through November 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the somatosensory testing provided on November 30, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that somatosensory testing is covered for the indications 
established in the applicable LCD.  
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 testing. Our reviewer says that the 
requested testing was not medically reasonable and necessary. Our physician reviewer found that the enrollee's 
surgery did not involve the spinal cord, and it was not a spinal surgery. Therefore, the testing was not provided 
for an indication supported within the LCD for coverage. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the somatosensory testing provided on November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve APOS shoes (T1999). 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition.  Therefore, we decided that the Plan does not have to pre-approve APOS 
shoes (T1999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system 
(HFCWOD) (E0483). 
 
You asked the Plan to pre-approve HFCWOD. You say that you are requesting reconsideration due to medical 
necessity. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show the enrollee does not have a qualifying disease or condition, such as a diagnosis of cystic fibrosis, 
bronchiectasis, or a neuromuscular disorder. 
 The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device 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 (HFCWOD) (E0483).
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 it is medically necessary. The Plan 
denied your request. The Plan says you do not meet the requirements for approval. 
 
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 you are an 82-year-old for whom admission to a long-term acute care hospital 
(LTACH) has been requested. At issue is whether LTACH services are medically necessary, reasonable, and 
appropriate for your diagnosis and condition. You have a medical history that includes diabetes, hypertension, 
and recently diagnosed stage III squamous cell carcinoma of the larynx. You were recently admitted to the acute care hospital with acute respiratory failure with a laryngeal mass with edema, pneumonia, and acute 
respiratory failure. A tracheostomy was placed on May 15, 2023. A gastrostomy tube was placed on May 16, 
2023. You were discharged home on May 19, 2023, and was readmitted to the hospital on May 20, 2023, 
following a fall. You received a coronary artery stent on May 22, 2023. You were taken to the operating room 
on May 23, 2023, for control of a tracheal stomal hemorrhage. On May 31, 2023, you were not in distress. You 
were too weak to go home. 
 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short-term acute care hospitals. You are 
receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that you in this case requires services at the LTACH that are not available at the acute care hospital 
where you are currently receiving care. There are no required medical services identified that are available at 
the LTACH, that are not available at the current health care setting being offered by the health plan. 
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hemoglobin, glycosylated (A1C) testing (83036) 
provided on October 10, 2022.  
You asked the Plan to pay for the A1C testing. You say that this should be covered. The Plan denied your 
request. The Plan says this testing is not covered when done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the A1C testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
hemoglobin, glycosylated (A1C) testing (83036) provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a consultation for temporomandibular joint (TMJ) dysfunction. 
 
You asked the Plan to pre-approve a consultation. You say that you have terrible TMJ. You say that your jaw 
barely opens, you cannot talk properly, and are in pain. You say that you cannot sleep, and you grind your 
teeth. You also say that this would cost you about $270 out-of-pocket and that is a lot of money for you. The 
Plan denied your request. The Plan says that the requested consultation is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically 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 consultation. Our reviewer says that 
the requested consultation is medically necessary. Our physician reviewer found the provided documentation 
supports there is a muscle-based issue causing pain and headaches and not an arthritic condition according to 
available documentation. The reviewer found that the documentation supports that the consultation is focused 
on the jaw function and not on structures that support the teeth given the current symptoms include pain on 
opening and frontal headaches. Therefore, the reviewer found that the requested consultation is 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 a consultation have been met. Therefore, we decided that the Plan has to pre-
approve a consultation for temporomandibular joint (TMJ) dysfunction.  
 
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.