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

 
We decided that the Plan has to pre-approve an Upwalker. 
 
You asked the Plan to pre-approve an Upwalker. You say that you need this for stability. The Plan denied your 
request. The Plan says that this is not covered by Original Medicare. 
 
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. The Plan argues that this item is not covered by Original Medicare. However, 
the Plan has not provided documentation supporting its denial. A Medicare rule was not provided showing that 
the requested item is not covered by Medicare. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pre-approve an Upwalker.  
 
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: 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 is at high risk for falling. The Plan 
denied your request. The Plan says the enrollee does not need an intensive team for 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 physician reviewer found 
that the enrollee was admitted to the acute hospital with frequent falls, memory loss, acute left leg laceration. 
The complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees functional level does not 
require treatment by multiple therapies in an intensive rehabilitation program. While the enrollee may be able 
to  benefit from additional therapy the documentation does not support that the enrollee requires this or can 
fully tolerate this therapy on an intensive level in an IRF.   
 
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 power scooter repairs. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says repairs to previously denied equipment are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment can be made for reasonable and 
necessary maintenance and service of beneficiary-owned DME that is not under a manufacturers or suppliers 
warranty. 
 
We looked at the file and Medicare rules. The file shows that you purchased the power scooter and it was not 
approved by the Plan. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve power scooter repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental 
pneumatic appliance, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you request 
reconsideration of this denial for authorization of a pneumatic compression device (E0651) and bilateral leg 
sleeves (E0667x2).  The Plan denied your request. The Plan says the records do not support that the enrollee 
meet the Medicare criteria. 
 
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. 
 
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 intermittent limb compression device 
and appliances. 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 lymphedema of the lower extremities 
for which compression stockings were tried but not tolerated. The provided documentation did not clearly show 
the enrollee having tried a 4-week trial of conservative treatments with leg measurements before and afterward 
to show failure in order to consider using the pneumatic compressor. Documentation did not mention how long 
compression stockings were tried or whether exercise or leg raising was tried. No measurements were 
documented before and afterward. Therefore, this request for such will be considered not medically necessary 
at this time based on the provided documentation.  
 
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 pneumatic compression device and appliances have not been met.  Therefore, 
we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental 
pneumatic appliance, full leg (E0667).
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 needs. The Plan denied your request. The Plan says ongoing skilled care can be provided in an 
alternative 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  
 
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 you had a stroke and cannot move, need to go to 
rehabilitation. The Plan denied your request. The Plan says the records we received do not show that you need 
two or more types of therapy (physical, occupational or speech). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autologous platelet rich plasma treatments (G0460). 
 
You asked the Plan to pre-approve autologous platelet rich plasma treatments. You say that the following 
clinical documentation supports the medical necessity of this procedure. The Plan denied your request. The 
Plan says this service is considered investigational as a treatment option for the enrollee's wounds.  
 
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 autologous platelet rich plasma 
treatments. 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 peripheral neuropathy and wounds on the 
feet having been treated with amputation, skin grafting, and general wound care. Autologous platelet rich 
plasma treatments were requested. However, the enrollee does not have diabetes as required to meet NCD 
criteria for this treatment. Therefore, the autologous platelet-rich plasma treatments will be considered 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 autologous platelet rich plasma treatments have not been met. Therefore, we 
decided that the Plan does not have to pre-approve autologous platelet rich plasma treatments (G0460).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the enrollee is in immediate need of this 
device which helps prevent pulmonary exacerbations and hospitalizations. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of the requested device. 
 
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 portable 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 Life 2000 home ventilator is being requested for use with very low set tidal volumes which is a level of 
support that could be provided by a bilevel positive airway pressure (BiPAP) device with average volume 
assured pressure support (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. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound cleansers.  
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that wound cleansers (A6260) or irrigating solutions are 
non-covered. 
 
We looked at the file and Medicare rules. The item at issue is wound cleansers described by code A6260. This 
item is denied by Medicare as non-covered. Therefore, we decided that the Plan does not have to pre-approve 
wound cleansers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ramp.  
 
You asked the Plan to pre-approve a ramp. You say that you need a ramp to be able to use your power 
wheelchair indoors and outdoors The Plan denied your request. The Plan says the requested ramp is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a ramp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion/lumbar laminectomy. 
 
You asked the Plan to pre-approve the services. You say that delaying surgery could prevent the enrollee from 
achieving maximum physical function. The Plan denied your request. The Plan says the documentation lacked 
notes regarding why the enrollee needs this specific surgery or notes outlining a specific surgical plan. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that dynamic flexion/extension films are not provided in order to potentially assess the amount of 
movement (instability) at the requested surgical level. Detailed documentation is not evident regarding 
potential impending/inevitable temporary intra-operative instability. No compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested lumbar spine fusion/lumbar laminectomy is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar spinal fusion/lumbar laminectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the device is medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental and investigational. There is more research 
needed 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22869, 22870).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy. 
 
You asked the Plan to pre-approve a capsule endoscopy. The Plan denied your request. The Plan says there is 
currently no indication for a wireless capsule endoscopy. 
 
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopy of the small bowel is 
considered medically reasonable and necessary when the conditions listed in the Medicare rules section of this 
letter have been met. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a capsule endoscopy. Our reviewer says 
that a small bowel capsule endoscopy is not medically appropriate at this time. Our physician reviewer found 
the enrollee does not have a condition as listed for coverage. Our reviewer also found that the enrollee had an 
upper endoscopy which confirmed a source of bleeding, and the anemia is stable, so small bowel endoscopy is 
not 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 capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a capsule endoscopy.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where the enrollee is 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.   
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 Cxbladder test (0012M) provided on January 23, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary.  The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on January 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on December 19, 2022, billed 
with procedure codes 74230, 72040, and 74240. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on December 19, 2022, billed 
with procedure codes 74230, 72040, and 74240.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that you do not agree with the denial of the requested 
PET scan. The Plan denied your request. The Plan says the enrollee does not meet criteria for a PET scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 a PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a computed tomography (CT) scan of the 
chest, abdomen, and pelvis was performed in the hospital and was negative. A PET/CT was ordered "out of the 
abundance of caution." The documentation does not support that a PET scan is indicated at this time to 
determine whether or not the enrollee is an appropriate candidate for an invasive diagnostic or therapeutic 
procedure, or to determine the optimal anatomic location for an invasive procedure, or to determine the 
anatomic extent of tumor when the recommended anti-tumor treatment depends on the extent of the tumor.  
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.