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

We decided that the Plan does not have to pre-approve a power wheelchair (K0011, K0013, K0098). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need this item. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that that a power wheelchair is covered if the beneficiary 
has the mental and physical capabilities to safely operate the power wheelchair that is provided or has a 
caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, 
willing, and able to safely operate the power wheelchair that is provided, and the beneficiary's home provides 
adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair 
that is provided. 
 
The file shows that your home is not wheelchair accessible and your needs can be met with your current 
manual wheelchair. The records also indicate you may not be able to safely operate a power wheelchair. This 
means that Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power wheelchair (K0011, K0013, K0098).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211). 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that the enrollee needs this. The Plan 
denied your request. The Plan says this exceeds the frequency limitation for this item. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, it covers only one complete or partial 
denture every five years. The record shows that the enrollee received complete dentures in January of 2017.  
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in need for prolonged 
inpatient care which would be best provided in the LTACH setting. The Plan denied your request. The Plan 
says the enrollee can receive all care she needs in the current hospital. There is no evidence that an LTACH can 
provide superior care. 
 
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 the enrollee was admitted to the hospital on October 5, 2020 with fluid retention after 
missing dialysis, and then since she has had problems with her throat swelling up, most recently 3 days ago 
(October 25, 2020). This episode required emergent treatment and she was admitted to the ICU with 
angioedema. She required intubation and mechanical ventilatory support and subsequently required 
tracheostomy and PEG insertion. She has required IV antibiotics and treatment for metabolic encephalopathy. 
 
There is no documentation provided requiring admission to a LTACH. The enrollee still requires acute hospital 
level of care services and is receiving appropriate care at the present acute care facility. The review has 
determined that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need to sit down while showering and do 
not want to fall. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ATN1 gene testing. 
 
You asked the Plan to pre-approve ATN1 gene testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that ATN1 testing is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ATN1 gene testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve ATN1 gene testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you believe that this semi-
electric hospital bed is necessary for this enrollee's condition. The Plan denied your request. The Plan says the 
records do not support the medical necessity of this bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the documentation does not show that the semi-electric hospital bed is medically necessary. 
Our physician reviewer found the enrollee is a 69 year old female with a past medical history of emphysema, 
hypertension, atrial fibrillation, arthritis and morbid obesity. A semi-electric hospital bed has been requested. 
 
The documentation does not show that the patient's condition requires position of the body in ways not feasible 
in an ordinary bed. There is no documentation that the patient requires frequent changes in body position or 
immediate changes in body position. There is no documentation that the patient's condition requires special 
attachments that cannot be fixed and used on an ordinary bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a proven service and should be 
allowed to treat the enrollee's condition. The Plan denied your request. The Plan says there is not sufficient 
support for this procedure in peer-reviewed literature. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee presents with severe back pain and symptoms of neurogenic 
claudication. There is imaging evidence of moderate L3/4 spinal stenosis and moderate to severe L4/5 
neuroforaminal stenosis. She has reportedly failed reasonable and/or comprehensive conservative treatment. 
Under consideration is a request for implantation of the Superion (Vertiflex) interspinous space device at L3/4 
and L4/5.  
 
Current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical 
condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in 
patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, 
from L1 to L5. This enrollee has moderate to severe spinal stenosis at the L4/5 level, which would not meet 
FDA indications. FDA contraindications include scoliosis and osteoporosis, that have not been adequately 
addressed in the medical records. There is radiographic evidence of levoscoliosis, with no documentation of the 
Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this post-
 menopausal 78-year-old female with osteoporosis documented on her past medical history. The Superion 
(Vertiflex) interspinous space device would not be considered the standard of care for the enrollee's medical 
condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for 
treatment of this enrollee's medical condition. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto 24mg-26mg tablet for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Entresto 24mg-26mg tablet 
for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says that the requested Botox is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does support that the requested Botox is medically reasonable or necessary. Our physician 
reviewer found the enrollee has overactive bladder and urge incontinence. Myrbetriq was not effective. Bladder 
Botox injections were initiated on January 29, 2018 and the last injection (300 IU) given on April 8, 2019. This 
enrollee has a diagnosis (overactive bladder) that meets the Medicare criteria for coverage of Botox. Therefore, 
the enrollee meets criteria for the requested Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve 
Botox.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit (J0885). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Retacrit. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Procrit. Our reviewer says that the drug 
is not medically necessary. Our physician reviewer found based on the medical records provided the enrollee 
has not tried and failed the required drug and there is no indication that the plan's required drug would likely be 
less effective and/or likely have adverse effects for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 there is no documentation provided requiring admission to a LTACH. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
facility. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 27, 2020 to April 25, 2020.  
 
You asked the Plan to pay for this service. You say that SNF admission was medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 
pay for this service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found the enrollee did not require skilled nursing services with  the specialized skill, knowledge and judgment 
of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment in a SNF during the dates in question.  
 
The enrollee did not have complex wound care, or other ongoing SNF level SN need during these dates. The 
functional level did not require skilled therapy services with the specialized skill, knowledge and judgment of a 
qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF.  
The enrollee did not require the services on 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 this service have not been met. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF) services provided to the enrollee from March 27, 2020 to April 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trial of a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the SCS trial. You say that the mental health evaluation did not say that you 
should not be allowed to have this device only that you need to have regular psychological care, which you are 
willing to do. The Plan denied your request. The Plan says you have noted uncontrolled, untreated psychiatric 
disorders which disallow coverage of the SCS at this time. 
 
The Plan follows Medicare rules. Medicare rules say that SCS placement is covered when found to be 
medically necessary by a multi-disciplinary team and psychological clearance is obtained. 
 
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 SCS trial. Our reviewer says that 
the documentation does not support the medical necessity of this service at this time. Our physician reviewer 
found the enrollee is a female with chronic pain from prior anterior and posterior spinal fusions. She is taking 
opiates and has had prior interventional therapy. The request is for a SCS. Her psychological evaluation states 
she has bipolar disorder and obsessive-compulsive disorder. She is not in an established psychological therapy 
relationship and has not demonstrated on-going stability. 
 
In this case, the patient does not have clearance from the psychologist and is not in a stable on-going 
psychological therapy course. Therefore, she does not meet the NCD criteria and the request is deemed not 
medically reasonable or necessary at this point. 
 
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 SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve trial of a spinal cord stimulator (SCS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement services (CPT 
14301 and CPT 14302) provided to the enrollee on January 20, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported in the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
CPT 14301: 
 
adjacent tissue transfer or rearrangement of any area; defect 30.1sq cm to 60.0 sq cm 
 
CPT 14302: 
 
adjacent tissue transfer or rearrangement of any area for each additional 30.0 sq cm, or part thereof (listed 
separately in addition to code for primary procedure) 
 
We asked our coding 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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported in the medical records submitted. Our coding reviewer found 
the operative report documents 16 x 18 cm closure was performed.  CPT 14301 would be reported for 20.1 sq 
cm to 60 sq cm closure, and CPT 14302 would be reported for each additional 30.0 sq cm.   Therefore, CPT 
14301 and CPT 14302 would not be billable in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for adjacent tissue transfer or rearrangement services (CPT 14301 and CPT 14302) provided to the 
enrollee on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for established patient home visit (99350) patient unstable or 
significant new problem requiring immediate physician attention, 60 min. provided September 16, 2019. 
 
You asked the Plan to pay for established patient home visit. You say that the enrollee is homebound and need 
medical services recent episode of hypoglycemia and syncope. In order to re-evaluate the decision you have 
attached medical records. The Plan denied your request. The Plan says this code is not supported by the 
medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93350 is established patient home visit, patient unstable 
or significant new problem requiring immediate physician attention, 60 min. 
 
We find that CPT code 93350 is not supported in the medical record. Specifically, a home visit cannot be billed 
by a physician unless the physician was actually present in the beneficiary?s home. the medical records show 
the submitted services were performed by a LVN. Based on this information, we decided that Medicare rules 
for coverage of established patient home visit have not been met. Therefore, we decided that the Plan does not 
have to pay for established patient home visit (99350) patient unstable or significant new problem requiring 
immediate physician attention, 60 min. provided September 16, 2019.