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

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and all accessories (A7035, A7036, A4604, A7030, A7039, E0562, A7028, A7029, A7031, A7032, 
A7033, A7038). 
 
You asked the Plan to pre-approve a CPAP device and accessories. You say that you disagree with the denial. 
The Plan denied your request. The Plan says no records were received to document the medical necessity of the 
request. 
 
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 a CPAP device and accessories have 
been met. Medical records, including a face-to-face encounter and a written order by your provider were not 
submitted or received by the Plan. Therefore, we decided that the Plan does not have to pre-approve a 
continuous positive airway pressure (CPAP) device (E0601) and all accessories (A7035, A7036, A4604, 
A7030, A7039, E0562, A7028, A7029, A7031, A7032, A7033, A7038).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography: sleep staging with 4 or more 
additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel 
ventilation, attended by a technologist (95811). 
 
You asked the Plan to pre-approve a sleep study. You say that the requested sleep study is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of a sleep study. 
 
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 sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not meet the criteria for coverage. The enrollee can undergo a home sleep 
apnea test (HSAT) and does not require an in-lab sleep study per documentation provided. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a polysomnography: sleep staging with 4 or more additional parameters of sleep, with 
initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist 
(95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance (E0486) to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve an oral appliance. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this item can be provided by an in-network 
provider. 
 
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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an oral 
appliance (E0486) to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosant in multiple incompetent veins 
and the stab phlebectomy of varicose veins. You asked the Plan to pre-approve injection of sclerosant in multiple incompetent veins and the stab 
phlebectomy of varicose veins. You say that the enrollee has a history of right greater saphenous vein (GSV) 
closure, and that the ultrasound shows absent GSV in the thigh, but an incompetent remnant phlebectomy. You 
say the enrollee has symptomatic bilateral lower extremity large varicose veins and associated with pain, 
discomfort, swelling, itching, cramping and skin discoloration affecting her daily activity despite trying 
compression stockings and daily walk exercises for more than 3 months in the past. The Plan denied your 
request. The Plan says the requested injection of sclerosant in multiple incompetent veins and the stab 
phlebectomy of varicose veins is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the requested services are covered when the criteria 
listed in the Medicare rules section of this decision are 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 injection of sclerosant in multiple 
incompetent veins and the stab phlebectomy of varicose veins. Our reviewer says that the requested injection of 
sclerosant in multiple incompetent veins and the stab phlebectomy of varicose veins is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the Medicare coverage 
criteria require that the varicosities to be treated with phlebectomy or sclerotherapy must not be associated with 
untreated saphenous reflux. In this case, there is documentation in the medical record that the patient has 
significant reflux in the remnant great saphenous vein that is in direct communication with an incompetent and 
tortuous anterior accessory saphenous vein and its associated tributaries. The communication of the large 
varicosities in the right leg with the remnant great saphenous vein both directly and via the accessory 
saphenous vein is not addressed in the treatment plan rationale. Therefore, the Medicare coverage criteria have 
not been met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection of sclerosant in multiple incompetent veins and the stab phlebectomy 
of varicose veins have not been met. Therefore, we decided that the Plan does not have to pre-approve injection 
of sclerosant in multiple incompetent veins and the stab phlebectomy of varicose veins.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy provided by a chiropractor on January 13, 
2023, to, July 13, 2023. 
 
You asked the Plan to pay for manual therapy. You say that based on your copayments, you should be 
reimbursed $210 for the visits on May 20, 2022, and July 22, 2022. You say that you should also be reimbursed 
$200 for the remaining four visits between August 19, 2022, and December 2, 2022. The Plan denied your 
request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for manual therapy provided by a chiropractor on January 13, 2023, to, July 13, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids.  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are available with an in-network 
provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when prescribed by a network provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that coverage is provided for 
hearing aids only when prescribed by a network provider. However, the hearing aids in this case were 
requested to be rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to 
pre-approve hearing aids.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport services 
received on May 9, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport. You say that the 
services were medically necessary. The Plan denied your request. The Plan says without transport there are no 
payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 9, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transport services received on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that you disagree with the denial. The Plan 
denied your request. The Plan says a CardioMEMS device was requested to help monitor the enrollee's heart 
failure control. This was denied as experimental/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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the Food and Drug Administration (FDA) 
in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary 
artery pressure in the management of enrollees with congestive heart failure (CHF). The clinical study on 
which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in enrollees 
in whom the CardioMEMS system was implanted, reflecting an enrollee population with preserved ejection 
fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in enrollee management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollee's 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items was exhausted on date of service August 16, 2021.  
  
 
 
 
 
Specifically, the Plans contract states that complete and partial dentures are covered once every 96 months. 
You previously received an upper and lower partial denture on August 21, 2023, less than 96 months prior, 
which were paid for by the Plan. Therefore, you have exhausted the allowable benefit for the requested dental 
items in this case. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower complete denture (D5120). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service September 13, 2022. Specifically, 
the Plans contract states that a lower complete denture is covered once every 60 months. You previously 
received this dental item on September 13, 2022, less than 60 months prior, which was paid for by the Plan.   
 
 
 
 
Therefore, you have exhausted the allowable benefit for the requested dental item in this case. Therefore, we 
decided that the Plan does not have to pre-approve a lower complete denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested dental items are not covered under the 
supplemental dental policy.  
 
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, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is able to feed herself and has adequate 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 the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits (G0299). 
 You asked the Plan to pre-approve home health services. You say that the requested home health visits are 
medically 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 reasonable and necessary. Our physician reviewer found the enrollee 
began skilled nursing service May 2023. On November 11, 2023, there was a recertification request. The 
enrollee was stable without changes and without evidence of risk for instability. Per chapter 7, the enrollee did 
not have a medical need for continued skilled services. She was stable after several months of home skilled 
nursing services. 
 
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 home health skilled nursing visits (G0299).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drug. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the self-administered drug.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 foot with multiaxial ankle (L5968, L5981). 
 
You asked the Plan to pre-approve a K3 foot with multiaxial ankle. You say that the provider is appealing with 
records. The Plan denied your request. The Plan says the records do not show why a K2 foot would not work 
for the enrollee. 
 
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 K3 foot with multiaxial ankle. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the treating nurse practitioner documentation does not support that the 
enrollee is a K3 ambulator. The document does not indicate a K level. The enrollee's activities can be met with 
a lower-level foot. The certified prosthetist/orthotist (CPO) note indicates a history of Charcot Marie Tooth 
with severe neuropathy and multiple orthopedic surgeries. Additionally, the nurse practitioner note indicates 
that the enrollee has chest pain at rest, is disabled, and does not exercise. A K2 foot would still allow 
ambulation on uneven surfaces. The K3 foot exceeds the enrollee's needs. 
 
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 K3 foot with multiaxial ankle have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a K3 foot with multiaxial ankle (L5968, L5981).
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the records do not show that the enrollee's 
condition can only be managed in a long-term acute care facility. The records do not include a recent chest  
x-ray that shows the enrollee's condition has stabilized or improved.  
 
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 enrollee has a past medical history significant for breast cancer, primary 
central nervous system (CNS) lymphoma, paroxysmal atrial fibrillation, a history of stroke, diabetes, and a prolonged hospital stay earlier this year for respiratory failure requiring intubation and tube feeding with 
subsequent placement at a skilled nursing facility. The enrollee was supposed to be on bilevel positive airway 
pressure (BiPAP) at night but was not tolerating it, potentially related to recent positive COVID test, and was 
found unresponsive and brought to the hospital. The enrollees mentation improved; they have dealt with 
cardiac arrythmias while in the hospital. The enrollee is on high flow nasal cannula during the day and BiPAP 
overnight. The enrollees needs are being met in their current setting and no therapeutic benefit is anticipated 
with an LTACH transfer. 
 
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.