Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) scan specifically focused on 
the temporo mandibular joint (TMJ) to assess TMJ disorders (70336). 
 
You asked the Plan to pre-approve the MRI. You say that your jaw shifted and is in a lot pain, you cannot sleep 
well or eat due to this pain and not able to fully open your mouth.  The Plan denied your request. The Plan says 
that Medicare does not pay "for services in connection with the care, treatment, filling, removal, or replacement 
of teeth or structures directly supporting teeth." The Plan states the request for special imaging (MRI) of your 
jaw joints for TMJ is not covered.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our physician reviewer found 
the documentation provided meets the criteria of medically reasonable and necessary for coverage of a bilateral 
MRI of the TMJ joint. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) scan specifically focused on the temporo mandibular joint (TMJ) to assess 
TMJ disorders (70336).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are unable to care independently for yourself at 
home. The Plan denied your request. The Plan says your condition does not meet the criteria for admission. 
Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital 
signs. You continued treatment with the wound vac, pain control and a course or oral antibiotics. Regarding 
rehabilitation services, you received physical therapy (PT) and occupational therapy (OT). You were at a 
standby assist/supervision to contact guard assist level with functional mobility including gait to 300 feet. You 
required varying assist with activities of daily living. There are identifiable skilled nursing service needs. There 
are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a 
daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that the documentation does not support that the enrollee has needs for complex 
medical treatment in an LTACH (e.g., multiple and prolonged intravenous therapies, monitoring of 
significantly medically active conditions requiring clinical assessment 6 or more times a day, multiple and 
frequent intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like 
cardiac monitors, on-site dialysis, or surgical suites). The enrollee does not require services at the LTACH that 
are not available at the acute-care hospital or the skilled nursing facility. 
 
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transport services. 
 
You asked the Plan to pre-approve the services. You say that you do not have a way of getting to your doctor's 
visits. The Plan denied your request. The Plan says the provider reports no need for assistance with ambulation. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair van transport services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no indication of failure on documentation, therefore, bilevel positive airway pressure (BIPAP) is appropriate therapy. There is no 
indication for home ventilation per documentation at this junction of the enrollee's therapy. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission. 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 that the enrollee is medically stable and does not need Physical Medicine and 
Rehabilitation physician's supervision three (3) times a week in an IRF. At the current functional level, the 
enrollee does not need specialized and intensive therapies consisting of at least three (3) hours of therapy per 
day at least five (5) days per week with multidisciplinary approach in an IRF. The documentation does not 
support necessity for admission to an IRF. The complexity of the enrollee's medical, rehabilitation, and nursing 
needs (combined complexity) does not require an acute hospital inpatient rehabilitation stay with an 
interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the services are 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 necessary. Our physician reviewer found the enrollee does not require 
continued skilled services. She has been educated and the wounds are healed. 
 
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 3 home health skilled nursing visits.
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 will benefit from the services at an IRF, 
the enrollee's needs are unable to be met at a lower level of care. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the services. Our reviewer says that the 
requested ventilator is not medically reasonable or necessary. Our physician reviewer found that continuation of use of a home ventilator is not medically necessary. The enrollee has severe COPD and was prescribed a 
home ventilator on July 22, 2022.  The circumstances at that time are not provided. An arterial blood gas was 
done on April 12, 2023, which showed mild compensated CO2 retention. The FEV1 is 26% of predicted with 
an obstructive pattern. There is no device download to document the enrollee's use of the device. It is 
prescribed in the noninvasive auto-titrating ventilation (AVAPS-AE) mode, which can be provided with 
BiPAP.  Medicare does not cover a home ventilator when used at settings that can be provided with bilevel 
positive airway pressure (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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options. 
 
You asked the Plan to pre-approve the requested Group 3 PWC. You say that the PWC requested is medically 
necessary.  The Plan denied your request. The Plan says the PWC with multiple power options does not meet 
criteria.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options may 
only be covered when the enrollee meets criteria for a power tilt and power recline seating system. 
 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 requested Group 3 PWC. Our 
reviewer says that the criteria for coverage of this PWC base with multiple power options are not met.  Our 
physician reviewer found the enrollee has paraplegia and decreased upper extremity strength. She has intact 
skin and does not have high risk for skin breakdown, use a catheter intermittently, or have spasticity or require 
an alternative means of managing power drive.  
 
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 requested Group 3 PWC have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous lysis of epidural adhesions. 
 
You asked the Plan to pre-approve a percutaneous lysis of epidural adhesions. You say that the enrollee has 
tried and failed multiple modalities of conservative care, including greater than 8 weeks of physician-guided 
home exercise.  The Plan denied your request. The Plan says that the percutaneous lysis of epidural adhesions 
is considered experimental and investigational.  
 
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 injection. Our reviewer says that the 
requested percutaneous lysis of epidural adhesions is not medically necessary. Our physician reviewer found 
that the requested procedure is not proven to be safe and effective for the enrollee's lumbar spine conditions. 
Also, there are insufficient randomized controlled trial studies supporting the long-term safety and efficacy of 
this procedure. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous lysis of epidural adhesions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466) and humidifier (E0562). 
 
You asked the Plan to pre-approve a ventilator and humidifier. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 ventilator and humidifier. Our reviewer says that the services are not medically necessary. Our physician reviewer found bilevel positive 
airway pressure (BIPAP) therapy is appropriate, per documentation provided, at this time. The records do not 
show documented failure or documented need for home ventilation. 
 
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 ventilator and humidifier have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a ventilator (E0466) and humidifier (E0562).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 31, 2022, to 
August 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this issue was caused by billing 
software which caused the incorrect admission date to be reported on the claim. This claim has since been 
corrected and should be reimbursed.  The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 31, 2022, to August 
29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical stimulation device for cancer treatment 
(Optune TTFT) (E0766). 
 
You asked the Plan to pre-approve the services. You say that the enrollee meets criteria for TTFT. The Plan 
denied your request. The Plan says the enrollee has not had an in-person clinical re-evaluation by the treating 
practitioner. 
 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 physician reviewer 
found there is no documentation provided that shows clinical re-evaluation demonstrating enrollee is benefiting 
from TTFT no sooner than 60th day, but no later than the 91st day after initiating therapy. Need to provide this 
documentation for continued 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve electrical stimulation device for cancer treatment (Optune TTFT) (E0766).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the request for K3 microprocessor feet does not meet Medicare criteria as reasonable 
and necessary. The Plan sates the records do not show why the requested computerized foot is needed and the 
requested prosthesis exceeds the enrollee's need.  
 
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 item. Our physician reviewer found 
the requested item exceeds the enrollee's medical and functional needs. The physician documentation does not 
support that the enrollee requires a microprocessor ankle foot system over a mechanical unit. The Certified 
Prosthetist/Orthotist (CPO) and physician documentation do not support extenuating activities that would be 
unable to be safely and effectively met with a mechanical foot.  
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or 
plantar flexion control, includes power source (L5973).