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

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and segmental 
pneumatic appliances for use with pneumatic compressor (codes E0656, E0657, E0668). 
 You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliances. You say that 
the enrollee is and has been experiencing worsening left upper extremity lymphedema despite four weeks of 
conservative therapy with compression, elevation, and exercise. You also say that the enrollee has tried basic 
pneumatic compression device which was discontinued due to no clinical improvement and exacerbation of 
symptoms. The Plan denied your request. The Plan says the records do not show that the enrollee tried the basic 
pump for the required daily four-week trial. 
 
The Plan follows Medicare rules. Medicare rules say that a four-week trial of conservative therapy 
demonstrating failed response to treatment is required for a PCD to be 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 pneumatic compressor and segmental 
pneumatic appliances. Our reviewer says that there is no documentation that the pneumatic compression device 
(E0652) and segmental pneumatic appliances for use with pneumatic compressor (codes E0656, E0657, E0668) 
at issue in this case meet all Medicare and LCD criteria for medically reasonable and necessary for the enrollee. 
Our physician reviewer found the provided records in this case do not document at least four weeks of regular, 
daily, multiple-hour home usage of a basic pump (E0650 or E0651) after careful, in-person fitting, training and 
supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided as 
required by the LCD.  
 
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 compressor and segmental pneumatic appliances have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and 
segmental pneumatic appliances for use with pneumatic compressor (codes E0656, E0657, E0668).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Entyvio. 
 You asked the Plan to pre-approve Entyvio. You say that starting the enrollee on Entyvio is best. The Plan 
denied your request. The Plan says the Plan requires a trial of Stelara before it will approve Entyvio. 
 
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 Entyvio. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Entyvio. Our physician reviewer found the 
enrollee has not tried and failed Stelara. The record does not show that this drug would likely be less effective 
and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Entyvio.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an IRF admission 
and could be harmed at a lower level of care. You would like reconsideration based on the records submitted.  
The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 that the enrollee is modestly deconditioned after spinal surgery and is walking above 
the home care level. The enrollee does not have intensive or complex rehabilitation and does not require 
frequent physiatry oversight. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided on 
August 31, 2022, through September 22, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided on August 31, 2022, through 
September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you would like the K0861 base, and all recommended components needed to meet the enrollee's current 
medical, mobility, and functional needs to be reconsidered for coverage. The Plan denied your request. The 
Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating leg 
rests), there is not a medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that 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, harness, and 
expandable controller. 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 an impaired right hip from 
infection and limited strength in their right upper extremity from a stroke. Strength in the enrollee's left upper 
extremity is 5 out of 5. Our reviewer also found that the enrollee has adequate upper body strength to manage 
standard power drives. 
 
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, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item 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.  
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 mechanical ventilator. Our 
reviewer says that the enrollee does not need this item. Our physician reviewer found the enrollee could be 
treated with a BiPAP machine with AVAPS capability and failure of such a device has not been documented. 
 
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 mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar fusion. 
 
You asked the Plan to pre-approve the surgical service. You say that the enrollee has completed physical 
therapy. You also say that this is medically necessary for the enrollee. The Plan denied your request. The Plan 
says the enrollee has not failed at least three months of nonoperative therapy. 
 
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 lumbar fusion. Our reviewer says 
that the requested lumbar fusion is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate that the enrollee has trialed at least 
three months of physical therapy. Therefore, the reviewer found that the lumbar fusion 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 lumbar fusion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lumbar fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 08, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 February 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided on 
November 3, 2022, through November 22, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided on November 3, 2022, 
through November 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvic ultrasound (76856) provided on January 14, 2023. 
 
You asked the Plan to pay for the pelvic ultrasound (76856). You say that the test was performed to look for 
ways to alleviate the enrollee's pain and treat the cyst. You say that the service was medically necessary, and 
the claim should be reprocessed for payment. The Plan denied your request. The Plan says the medical records 
do not support procedure code 76856. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
  In this case, the CPT Code Manual definition of code 76856 is ultrasound, pelvic (non-obstetric), real time with 
image documentation; complete. 
 
We asked our coder 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 pelvic ultrasound (76856). Our reviewer says that the 
documentation does not support code 76856. Our reviewer found the documentation shows that a limited 
ultrasound was performed not a complete ultrasound. There is a more specific code for the procedure 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the pelvic ultrasound (76856) have not been met. Therefore, we decided that the 
Plan does not have to pay for the pelvic ultrasound (76856) provided on January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that you need the 
scooter because of the pain you have in both knees when standing and walking, and your right knee is worse. 
You also say that you were advised surgery is not recommended for you. The Plan denied your request. The 
Plan says the requested powered operated vehicle (scooter) is not medically necessary under Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 group 1 standard power operated 
vehicle. Our reviewer says that you do not meet the coverage criteria for a group 1 standard power operated 
vehicle. Our physician reviewer found you are able to ambulate on flat surfaces with a walker. Our reviewer 
also found that you are able to complete MRADLs in your home. 
 
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 group 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary.  
 
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 that the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services at a lower 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on December 16, 2022, by an OON 
provider.  
 
You asked the Plan to pay for a drug test. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says this service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a drug test provided on December 16, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bitewing x-ray (D0274), full mouth debridement 
(D4355), intraoral periapical each additional image (D0230) and core buildup (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the bitewing x-rays and intraoral periapical each additional image 
has already been exhausted. 
 
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. Therefore, we decided that the Plan does not have to pre-approve bitewing x-ray (D0274), full mouth debridement (D4355), intraoral periapical each 
additional image (D0230) and core buildup (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of sclerosant (36470). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee continues to be symptomatic after 
attempting compression therapy, leg elevation and diet changes. You say that the enrollee has had a previous 
procedure with a positive relief of symptoms. You also say that the enrollee feels they would benefit from 
having this procedure again. The Plan denied your request. The Plan says there was not enough documentation 
provided to determine if the coverage criteria for this service have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injection have been met. 
Specifically, the file does not provide specific documentation indicating the enrollee's diagnosis or anything 
about the enrollee's condition or treatment plan. Without this information, it cannot be determined if this 
service is medically necessary. Therefore, we decided that the Plan does not have to pre-approve the injection 
of sclerosant (36470).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor 
(implantable loop recorder - ILR) (33285). 
 
You asked the Plan to pre-approve the ILR. You say that you want to appeal this denial. The Plan denied your 
request. The Plan says the records show that the enrollee had outpatient ambulator heart monitoring which 
showed their supraventricular tachycardia (SVT) problem. The Plan also says that this procedure 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 the ILR. Our reviewer says that the 
requested ILR is not medically necessary. Our physician reviewer found the provided documentation does not 
support that the enrollee has had recurrent syncope of uncertain etiology over the past year, no cryptogenic 
cerebral vascular accidents (CVAs), and no unrevealing noninvasive cardiac monitoring. Therefore, the reviewer found that the requested ILR 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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the insertion, subcutaneous cardiac rhythm monitor (implantable loop recorder - ILR) (33285).