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

 
We decided that the Plan does not have to pre-approve a heavy-duty wheelchair 
 
You asked the Plan to pre-approve the wheelchair. You say that the wheelchair provided to you is too small for 
your body. You need a large durable wheelchair that will support your 6 foot 3 and 210 pound body. The Plan 
denied your request. The Plan says the enrollee does not meet the coverage criteria for the requested heavy-
duty wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an ultralightweight wheelchair (K0005). A heavy-duty wheelchair serves the 
same purpose as the wheelchair. The rules also says that you must weigh more than 250 pounds and the enrollee also is only 210 pounds and does not meet the criteria for the requested wheelchair. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty wheelchair
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) radiofrequency. 
 
You asked the Plan to pre-approve SIJ radiofrequency. You say that the service is necessary. The Plan denied 
your request. The Plan says the requested service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SIJ radiofrequency have not been met. Therefore, we decided that the Plan does not have to pre-
approve sacroiliac joint (SIJ) radiofrequency.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, low intensity ultrasound, 
non-invasive (E0760). 
 
You asked the Plan to pre-approve a bone growth stimulator. You say that the enrollee needs this device. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 bone growth stimulator. Our reviewer 
says that the requested bone growth is not medically necessary. Our physician reviewer found the provided 
records do not document nonunion of a fracture documented by a minimum of two sets of radiographs obtained 
prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Therefore, the 
reviewer found that a bone growth stimulator 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 a bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, low intensity ultrasound, non-invasive (E0760).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the customized seat cushion (E2609) and customized 
seat back (E2617). 
 
You asked the Plan to pre-approve the customized cushions. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that a custom fabricated seat cushion (E2609) is covered 
if criteria (1) and (3) are met. A custom fabricated back cushion (E2617) is covered if criteria (2) and (3) 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 the customized cushions. Our reviewer 
says that the enrollee does not need these items. Our physician reviewer found the documentation does not 
indicate that the enrollee has significant postural changes that would require specialized cushions for the new 
wheelchair. 
 
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 customized cushions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the customized seat cushion (E2609) and customized seat back (E2617).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound screening study for AAA. 
 
You asked the Plan to pay for an ultrasound AAA screening. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that payment may be made for a one-time ultrasound 
screening for AAA for enrollees who meet the criteria listed in the Medicare rules section of this letter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an ultrasound AAA screening have not been met. Specifically, the provided medical record does 
not address whether the enrollee is included in at least one qualifying risk category. Therefore, we decided that 
the Plan does not have to pay for an ultrasound screening study for AAA.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency ambulances services (A0427, A0425) billed for 
January 6, 2023. 
 
You asked the Plan to pay for emergency ambulances services. You say that the services at issue were a 
medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say the GY modifier must be used 
when the item or service is statutorily non-covered or is not a Medicare benefit. 
 
We find that CPT codes A0427 and A0425 are not supported. Specifically, the codes at issue have been billed 
by the service provider with a GY modifier, indicating the codes are statutorily non-covered or are not a 
Medicare benefit. Based on this information, we decided that Medicare rules for coverage of emergency ambulances services have not been met. Therefore, we decided that the Plan does not have to pay for 
emergency ambulances services (A0427, A0425) billed for January 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair replacement. 
 
You asked the Plan to pre-approve a power wheelchair replacement. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the enrollee 
refused to provide the police report for the theft of the power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage. 
 
We looked at the file and Medicare rules. There is no evidence confirming that the enrollees power wheelchair 
was stolen. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for sacroiliac joint (SIJ). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has been treated in the past with a 
SIJ injections and lateral branch blocks with great relief. You say that the requested injection would give the 
enrollee prolonged relief. The Plan denied your request. The Plan says the requested injection is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation is not considered reasonable and 
necessary. 
 
We looked at 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 
radiofrequency ablation (RFA) for sacroiliac joint (SIJ).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Invitae next-generation sequencing (NGS) panel. 
 
You asked the Plan to pre-approve the Invitae panel. You say that  the records provided support the need for 
the requested panel. The Plan denied your request. The Plan says the guidelines for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of germline testing may be allowed when 
the criteria listed in the Medicare rules section 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 the Invitae panel. Our reviewer says 
that the requested testing is not shown to meet coverage criteria. Our physician reviewer found the enrollee is a 
71-year-old male who was referred to oncology/hematology for monocytosis and left shift and mild anemia. It 
was noted that he had a history of prostate cancer diagnosed at age 48. Prostate biopsy results from 2017 
showed adenocarcinoma (Gleason 3+3=6). Germline testing was prescribed. A request for Invitae Prostate 
Cancer Panel was made. The provided documentation does not clearly show evidence of a germline cancer 
inherited from family. Also, there was insufficient evidence showing metastatic disease from prostate cancer to 
meet the required NCD criteria.  
 
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 Invitae panel have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Invitae next-generation sequencing (NGS) panel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure (B4150). 
 
You asked the Plan to pre-approve Ensure. You say that the enrollee has chronic protein caloric malnutrition 
with continued weight loss. You also say that Ensure should be used to assist in treatment. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare requirements for nutritional 
supplementation. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them.  Therefore, we decided that the Plan 
does not have to pre-approve Ensure (B4150).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthetic leg (codes L5871, L5984, 
L5987, and L5988). 
 
You asked the Plan to pre-approve a replacement prosthetic leg. The Plan denied your request. The Plan says 
the request of new prosthetic foot exceeds member's functional need and does not meet the Medicare criteria of 
reasonable and 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 a replacement prosthetic leg. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the physician assistant documentation does not reveal a detailed 
musculoskeletal exam or gait evaluation. The physician assistant document is conflicting stating the enrollee is 
a high K3 ambulator and also stating the enrollee is a high impact K4 ambulator. Our reviewer found the 
physician assistant document is conflicting stating that the enrollee completes high impact activities such as 
skiing, yet the same document states the enrollee has not returned to skiing. The documentation does not 
support that the enrollee's functional needs and activities cannot be met with his current K3 foot. Our physician 
reviewer found that the documentation does not support that the enrollee's current foot is in disrepair and the 
foot is still under warranty. The L5871 also exceeds the enrollee's needs. The use of vacuum pumps for residual 
limb volume management and moisture evacuation systems among lower extremity amputees is unproven and 
not medically necessary due to insufficient evidence of safety and/or efficacy. Our reviewer also found that the 
requested L5781 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 a replacement prosthetic leg have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a replacement prosthetic leg (codes L5871, L5984, L5987, and L5988).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 14060 provided on December 15, 2022. 
 
You asked the Plan to pay for procedure code 14060. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 14060 is not supported in the medical record. Specifically, this service is included in the 
90-day global surgery package of code 14040 which was provided on September 22, 2022. Based on this 
information, we decided that Medicare rules for coverage of procedure code 14060 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 14060 provided on December 15, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 60-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips for 
dialysis. The Plan denied your request. The Plan says you have exhausted your transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
60-trip limit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a Barostim Neo system. 
 
You asked the Plan to pre-approve implantation of a Barostim Neo system. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 implantation of a Barostim Neo system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there remains an absence of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a 
result, at this time the Barostim Neo system would not be considered medically reasonable and necessary 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 implantation of a Barostim Neo system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of a Barostim Neo system.
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 has deconditioned in the hospital and 
needs therapy. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift (E0630). 
 
You asked the Plan to pre-approve a patient lift. You say that the enrollee requires the assistance of more than 1 
person to safely perform transfers. You also say without the use of a lift, the enrollee would be confined to bed 
and would require emergency medical services to be called when they fall. The Plan denied your request. The 
Plan says the enrollee clearly is not bed confined, and Medicare criteria for coverage of a lift are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a patient lift described by codes E0630 is covered if 
the basic coverage criteria 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 a patient lift. Our reviewer says that the 
enrollee does not meet the criteria for coverage. Our physician reviewer found the documentation does not 
support that the enrollee requires a mechanical lift for transfers or that they would be bed bound without a 
mechanical lift. Our reviewer also found that the enrollee is able to ambulate household distances with a walker 
and contact guard assistance. 
 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 patient lift have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a patient lift (E0630).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SmartVest Airway Clearance System high frequency 
chest wall oscillation device (HFCWOD). 
 
You asked the Plan to pre-approve HFCWOD. You say that you feel the enrollee would benefit from this 
device. The Plan denied your request. The Plan says the device is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a SmartVest Airway Clearance System high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 6, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on December 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 22, 2022, billed 
with procedure code 73720-26-RT. 
 
You asked the Plan to pay for the imaging service provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this code was billed with an invalid procedure 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that the procedure code billed must be assigned with 
the appropriate modifier when billed with a diagnosis code that indicates laterality.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging service provided have not been met.  In this case, code 73720-RT was billed with 
diagnosis code M79.605, described as pain in left leg. As such this service cannot be paid as billed. Therefore, 
we decided that the Plan does not have to pay for imaging services provided on December 22, 2022, billed with 
procedure code 73720-26-RT.