Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan Tablet. 
 
You asked the Plan to pre-approve Xifaxan Tablet. You say that you want the enrollee to be treated with this 
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Xifaxan Tablet.  
 
Benefits for Xifaxan Tablet 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 hospital bed, variable height, hi-lo, with any type side 
rails, with mattress (E0255). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is 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 DME. Our physician reviewer 
found the records do not discuss the medical conditions or physical needs and limitations for the requested 
hospital bed. Without the support of the documentation, medical necessity cannot be determined. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve hospital bed, variable height, hi-lo, with any type side rails, with mattress (E0255).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myocycle Home FES cycling therapy system. 
 
You asked the Plan to pre-approve the Myocycle. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Myocycle have not been met. The requested service has not been validated through well 
designed clinical studies to show any form of meaningful benefit. The studies that have been done with FES 
cycling technologies have primarily been conducted in attended/research centers. Studies have not been done 
with these devices in the home environment. There is also not evidence that the requested technology affords 
any significant health benefits either. Therefore, the service is not considered medically necessary Therefore, 
we decided that the Plan does not have to pre-approve Myocycle Home FES cycling therapy system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extra heavy duty wheelchair (K0007), for the enrollee. 
 
You asked the Plan to pre-approve the extra heavy duty wheelchair. You say that the DME is medically 
necessary. The Plan denied your request. The Plan says the DME is 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 extra heavy duty wheelchair. Our 
physician reviewer found based on the medical records provided there is no documentation that the beneficiary 
has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related 
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary 
locations in the home. There is no documentation that the beneficiary?s mobility limitation cannot be 
sufficiently resolved by the use of an appropriately fitted cane or walker. There is no documentation that the 
beneficiary?s home provides adequate access between rooms, maneuvering space, and surfaces for use of the 
manual wheelchair that is provided. There is no documentation that use of a manual wheelchair will 
significantly improve the beneficiary?s ability to participate in MRADLs and the beneficiary will use it on a 
regular basis in the home. There is no documentation that the beneficiary has not expressed an unwillingness to 
use the manual wheelchair that is provided in the home. There is no documentation that the beneficiary has 
sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the 
manual wheelchair that is provided in the home during a typical day. There is no documentation that the 
beneficiary has a caregiver who is available, willing, and able to provide assistance with the 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 extra heavy duty wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve extra heavy duty wheelchair (K0007), for the enrollee.
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 services 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on July 2, 2020 for septic shock, necrotizing fasciitis, and acute respiratory failure with hypoxia. She 
was sent to a long term acute care hospital (LTACH) on July 31, 2020 for respiratory management, wound 
care, and long-term intravenous antibiotics. The complexity of her nursing, medical, and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She 
may benefit from further therapy but does not require an intensive therapy program in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the provider will be the best fit for you. The 
Plan denied your request. The Plan says there are in-network cardiologists available. 
 
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 
cardiology services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fentanyl patches. 
 
You asked the Plan to pre-approve Fentanyl patches. You say that the medication is beneficial for her daily 
living. The Plan denied your request. The Plan says the drug is not covered for the enrollee's condition under 
Medicare Part B. 
 
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 Fentanyl patches.  
 
Benefits for Fentanyl patches 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has received an exceptional 
result from the last injection. The Plan denied your request. The Plan says there is no record of quantified 
improvements in pain, or examples of functional gains. 
 
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 requested services. Our physician 
reviewer found that the enrollee has left hip pain and low back pain which radiates down the left leg. The 
enrollee has already had 3 prior sacroiliac joint injections in October, February, and June. The last injection 
was on June 16, 2020. This request is for a fourth sacroiliac joint injection. The prescriber has not submitted 
records documenting quantified improvements in pain or examples of functional gains following prior 
sacroiliac joint injections. Coverage for the requested procedure, sacroiliac joint injection, following 3 prior 
injections without documentation of the prior procedures outcomes is not medically reasonable.  Based upon 
the records provided this request does not meet the definition of medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve the device. You say that neurogenic intermittent claudication is a major 
contributor of pain, disability, loss of production, loss of independence and disruption in her normal daily 
activities. The Plan denied your request. The Plan says there is lack of scientific evidence regarding the 
effectiveness of this device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interlaminar/interspinous process stabilization/distraction device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve colostomy supplies from an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON colostomy supplies. You say that you have been receiving you 
colostomy supplies through the OON provider since 2014 and don't want another provider. You say that the 
Plan previously authorized use of this OON provider for a 6 month span. The Plan denied your request. The 
Plan says it is not medically necessary for the colostomy supplies to be provided out of network. The Plan says 
that a network gap does not exist and that there are in network providers available who can provide the 
colostomy supplies. 
 
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 
colostomy supplies from an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower partial denture. 
 
You asked the Plan to pre-approve the lower partial denture. You say that you need a lower partial denture so 
you are able to chew food. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
lower partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cooling vest. 
 
You asked the Plan to pre-approve the cooling vest. You say that the cooling vest is medically necessary. The 
Plan denied your request. The Plan says the item is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cooling vest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair transit securement (K0108). 
 
You asked the Plan to pre-approve the transit securement. You say that this accessory is medically necessary. 
The Plan denied your request. The Plan says the transit securement is for use outside the home and is therefore 
not covered. 
 
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 pre-approve a power wheelchair transit securement (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant /abutment supported removable denture for 
edentulous arch (D6110) for tooth #9. 
 
You asked the Plan to pre-approve implant /abutment supported removable denture for tooth #9. You say that 
this procedure is medically necessary according to your dentist. The Plan denied your request. The Plan says 
this service is not covered under your benefit package. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
implant /abutment supported removable denture for edentulous arch (D6110) for tooth #9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) of the 
upper right quadrant. 
 
You asked the Plan to pre-approve the scaling and planing of the upper right quadrant. The Plan denied your 
request. The Plan says the documentation does not demonstrate evidence of significant bone loss and/or 
radiographic root-surface calculus on 4 or more teeth per quadrant that is required to qualify the enrollee for 
this procedure under the Plan. 
 
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. The Plan covers the scaling 
and planing of the upper right quadrant when the services are medically necessary and reasonable.  
 
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 scaling and planing of the upper 
right quadrant. Our reviewer says that the criteria for coverage for periodontal scaling and root planing (D4341) 
of the upper right quadrant have not been met. Our physician reviewer found there are less than 4 teeth in the 
maxillary right quadrant, and there is no documentation of pathological periodontal pockets. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scaling and planing of the upper right quadrant have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing 
(D4341) of the upper right quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-routine dental services. 
 
You asked the Plan to pre-approve the non-routine dental services. You say that your tooth broke off and your 
gums were bleeding. You also say that this was an injury to your mouth, and should be considered medical. 
The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve non-routine dental 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collagen based wound filler, dry form, sterile, per gram of 
collagen (A6010) and foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive 
border, each dressing (A6212) provided to the enrollee on February 12, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Healthcare Common Procedure 
Coding System (HCPCS) code A6010 A2 (24 Units) remains not supported. The documentation submitted did 
not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. Of note, 
the Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery 
include an order number or details to corroborate the Delivery Ticket submitted. Therefore, the billed supply 
code and its units cannot be verified.  It is noted that multiple attempts were made to contact the provider for 
additional information.  
 
Healthcare Common Procedure Coding System (HCPCS) code A6212 A2 (24 Units) remains not supported. 
The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific 
supplies, or proof of delivery. Of note, the Delivery Ticket submitted did not include the carrier's tracking 
number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket 
submitted. Therefore, the billed supply code and its units cannot be verified.  It is noted that multiple attempts 
were made to contact the provider for additional information. Therefore, we decided that the Plan does not have 
to pay for collagen based wound filler, dry form, sterile, per gram of collagen (A6010) and foam dressing, 
wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing (A6212) provided 
to the enrollee on February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT 
Code 70450) provided to the enrollee on March 9, 2020. 
 
You asked the Plan to pay for the CT scan. You say that it is appropriate to bill CPT 70450 and computed 
tomographic angiography, head, with contrast material(s), including non-contrast images, if performed, and 
image postprocessing (CPT Code 70496) together when medically necessary. The Plan denied your request. 
The Plan says procedure code 70450 was denied as the column II code to the column I code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. 
Procedure code 70450 was denied as the column II code to the column I code 70496. Per review of medical 
records, documents received supports CPT code 70450 being performed as a separate and distinct services 
performed during a different session by the denied provider, but an appropriate modifier has not been 
appended. Therefore, we decided that the Plan does not have to pay for the CT scan, head or brain; without 
contrast material (CPT Code 70450) provided to the enrollee on March 9, 2020.