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 you quit smoking in 2011. You need this 
machine to obtain quality of life. The Plan denied your request. The Plan says the request is not medically 
necessary because the records show that the ordered settings for the noninvasive ventilator can be delivered by 
a bi-level PAP machine with AVAPS capability. 
 
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 you have a diagnosis of chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document that the 
Life2000 home ventilator is being requested for use with very low set tidal volumes (150 to 200 mL) 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 average volume assured pressure support (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. Records also show 
you already have a home ventilator with no indication it has been lost, stolen, irreparably damaged in a specific 
accident or natural disaster or has reached its reasonable useful lifespan to meet Medicare criteria 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 1, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this does not need authorization. The Plan denied 
your request. The Plan says out-of-network services require authorization. 
 
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 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 an office visit provided on January 1, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4649 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code A4649. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code A4649 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4649 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4649 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4649 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4649 billed for date of service November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraoperative radiation treatment (IORT) delivery, x-
ray, single treatment session (77424). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient evidence supporting the use of IORT in this setting. Evidence on its safety 
remains unclear 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intraoperative radiation treatment (IORT) delivery, x-ray, single treatment session (77424).
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 services are needed due to loss of mobility, skin 
breakdown, and risk of falls. The Plan denied your request. The Plan says the IRF services you are requesting 
do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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: 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 the enrollee does not require skilled nursing or therapy services on a daily basis. This 
enrollee does 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external mobile cardiovascular telemetry with 
electrocardiographic recording (93228). 
 
You asked the Plan to pre-approve outpatient cardiac telemetry. You say that you have abnormal heart 
functions, and you need this service monitored for your health. The Plan denied your request. The Plan says the 
request is not medically necessary because your records show a Holter monitor was recommended post hospital 
evaluation. There is no documentation that prolonged monitoring is needed to provide additional clinical 
information. 
 
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 outpatient cardiac telemetry. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you were evaluated in the hospital and an outpatient ambulatory ECG 
monitor was recommended. Documentation does not show the test result or whether it was performed. There is 
no supportive evidence that the ordering practitioner documented a standard, non-MCOT, ambulatory ECG 
monitoring. In summary, there is insufficient documentation to support the medical necessity for an MCOT 
monitor in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient cardiac telemetry have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external mobile cardiovascular telemetry with electrocardiographic 
recording (93228).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of anesthetic agent, diagnostic or therapeutic 
procedures on the somatic nerves (64483) and injection(s), anesthetic agent and/or steroid, transforaminal 
epidural, with imaging guidance; lumbar or sacral, each additional level (64484) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve injections. You say that the enrollee is in severe pain and any delay in 
service/procedure may lead to a loss of function or enrollee's ability to regain maximum benefits. The Plan 
denied your request. The Plan says the enrollee must use in-network providers to receive services. There are 
available in-network providers who can provide this service. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
injection of anesthetic agent, diagnostic or therapeutic procedures on the somatic nerves (64483) and 
injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance; lumbar or sacral, 
each additional level (64484) to be provided by an out-of-network (OON) provider.
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 the enrollee is medically stable to be discharged to 
SNF.  The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 the enrollee does not have any parental medication; complex wound care or nutrition 
given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical 
problems. The enrollee's physical function is at or near the enrollee's baseline and the enrollee can receive 
services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows advanced lumbar facet degenerative 
joint disease (DJD) and foraminal stenosis. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says that the additional information 
requested was not received after multiple attempts. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the excess. 
 
We looked at the file and Medicare rules. The additional information received shows that the cost of the repairs 
to your current power wheelchair are less than the cost of a replacement power wheelchair. Therefore, we 
decided that the Plan has to pre-approve power wheelchair repairs.  
 
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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device will allow the enrollee 
to be more mobile. The Plan denied your request. The Plan says a review of the current medical literature does 
not consider this device to be standard medical treatment for your condition. The Life2000 system is not a true 
ventilator because it is not capable of providing full ventilatory support. It is designed primarily for use during 
activity. 
 
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 obstructive pulmonary disease with pulmonary hypertension, but records do not document chronic 
respiratory failure. Provided records document that the Life2000 home ventilator is being requested for use 
with very low set tidal volumes (150 mL to 200 mL) which could be provided by a 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. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation treatments (64635, 64636). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had previous radiofrequency ablation treatments, but there is no 
documentation of the percent of pain relief. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation treatments (64635, 64636).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (22869, 
00630, 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. 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. More research is needed. 
 
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 the Vertiflex superion device placement surgery (22869, 00630, 22870).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the proton beam therapy (PBT). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not 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 services. Our physician reviewer 
found they do not think that proton therapy is investigational, but rather whether or not it is superior to non-
proton-based intensity-modulated radiation therapy (IMRT), for routine use, is an investigational question. 
Furthermore, our physician reviewer found the requested services are favorable as the LCD criteria (which 
align with the American Society for Radiation Oncology (ASTRO) model policy criteria) are 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve the proton beam therapy (PBT).  
 
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.