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

 
We decided that the Plan does not have to pre-approve a CardioMems device for the enrollee. 
 
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan 
denied your request. The Plan says this device is not covered by Medicare. 
 
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 this device. 
Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the efficacy of the 
CardioMems heart failure system remains uncertain at this time. Further clinical study is needed to determine 
the efficacy and safety of this device. Medicare considers this device to be investigational. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
CardioMems device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that you live alone and cannot reach 
high, but you do not have the money to afford this feature. The Plan denied your request. The Plan says the 
denial of authorization for this device is correct, because a power seat elevation feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered 
because it is not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation feature.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve azelaic acid gel 15%. 
 
You asked the Plan to pre-approve azelaic acid gel. You say that you have used this cream for many years. You 
say that you need it to lessen the redness on your face. You also say that it is much needed. The Plan denied 
your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered 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 azelaic acid gel 15%.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injection services. 
 
You asked the Plan to pre-approve the facet injection services. You say that the enrollee has pain in the low 
back and radiating to bilateral legs. You say that the requested injections have shown to improve low back pain 
and are considered conservative management for pain that can be used to try and stop the use of opioids. The 
Plan denied your request. The Plan says the injections requested are not supported because the enrollee does 
not have the type of pain for which they are covered. 
 
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 facet injection services. Our 
reviewer says that the requested injection services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is a morbidly obese woman who has chronic low back pain 
and hip pain. She takes hydrocodone and Topical THC balm for pain. The physician documents lumbar 
radiculopathy and facet joint pain. The physical exam notes pain on facet loading and decreased range of 
motion but does not document her hip or the physical findings associated with the diagnosis of radiculopathy. 
The lack of documentation and the presence of radiculopathy do not meet the LCD criteria for diagnostic facet 
injections.  The request is 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 facet injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet injection services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) scan of leg 
(73718). 
 
You asked the Plan to pre-approve the MRI scan of leg. You say that the MRI is medically necessary. The Plan 
denied your request. The Plan says rules for an MRI have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI scan of leg. Our reviewer says 
that the requested service is not medically necessary. Our physician reviewer found the patient is a 72-year-old 
male with diagnosed left lower leg pain and tightness in mornings following left knee arthroplasty a few 
months prior. MRI left leg was requested. MRI is not indicated to confirm muscle strain and no other condition 
required ruling out based on the documentation provided. Therefore, MRI left lower extremity is not supported 
and will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI scan of leg have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the magnetic resonance imaging (MRI) scan of leg (73718).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total electric hospital bed. 
 
You asked the Plan to pay for the total electric hospital bed. You say that given the extenuating circumstances 
surrounding COVID-19 and medical supplies, the equipment purchased should be covered no matter where it 
was purchased even if not from an approved provider. The Plan denied your request. The Plan says this item is 
not covered under Medicare and the provider is not a certified Medicare provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital 
bed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retroperitoneal ultrasound (CPT 76770) provided to the 
enrollee on April 21, 2020. 
 
You asked the Plan to pay for the ultrasound. You say that this should be paid for. The Plan denied your 
request. The Plan says there is a more appropriate code to use. 
 
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 76770 is "Ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation; complete." 
 
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 the ultrasound. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found a review 
of the operative report indicates intraoperative ultrasound was done on 4/21/20 regarding the right kidney. A 
complete retroperitoneal ultrasound requires documentation of all of the following: aorta, vena cava, both 
kidneys, lymph nodes and aortic bifurcation. The ultrasound noted in the op report describes no such 
documentation. For the purpose of surgical intervention and the evaluation of the right renal mass prior to 
partial right nephrectomy a more appropriate code would have been for retroperitoneal ultrasound, CPT 76775. 
This would have been the appropriate code as the vascular structures and the left kidney in the retroperitoneum 
were not described and documented in the exam done on 4/21/20. 
 
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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for a retroperitoneal ultrasound (CPT 76770) provided to the enrollee on April 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound guidance for vascular access (76937) provided on 
September 9, 2020. 
 
You asked the Plan to pay for the ultrasound guidance. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this service was not billed with an 
appropriate primary procedure code. 
 
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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure)  
 
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 the ultrasound guidance. Our reviewer says 
that CPT code 76937 does not meet criteria for billing or reimbursement consideration. Our physician reviewer 
found the documentation does not note the potential sites that were evaluated, the patency of the selected site or 
the visualization of needle entry.  Additionally, no permanent recording of the image(s) is included in the 
documentation. 
 
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 ultrasound guidance have not been met. Therefore, we decided that the Plan 
does not have to pay for ultrasound guidance for vascular access (76937) provided on September 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips. 
 
You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the 
additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage 
exceeds the benefit limit. Therefore, coverage criteria has not been met. 
 
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 Plan?s coverage rules apply in this 
case. The Plan covers 60 one-way transportation trips per calendar year when each one-way trip does not 
exceed 75 miles per year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan?s rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage for routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from April 22, 
2020, to September 30, 2020. 
 
You asked the Plan to pay for home infusion therapy. You say that nothing was delivered to the enrollee, and 
this claim should be paid by the Plan. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because procedure code S9328 is not valid for Medicare purposes and is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy services provided from April 22, 2020, to September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel SureClick. 
 
You asked the Plan to pre-approve the Enbrel SureClick injector. You say that the enrollee is stable on this 
medication and cannot be forced to change to a new one. The Plan denied your request. The Plan says this self-
injected drug is not covered by 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 Enbrel SureClick.  
 
Benefits for the Enbrel SureClick injector 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 Onabotulinum toxin injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this drug for the enrollee's condition is not approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee is an 80 
year old male with diagnosed Raynaud's syndrome. Botox was requested. This diagnosis is not an FDA 
approved indication for Botox use and does not have sufficient supportive high quality evidence in the 
compendia to justify its use for this condition at this time. Therefore this request for Botox will be considered 
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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Onabotulinum toxin injection for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Doxil (doxorubicin liposomal). 
 
You asked the Plan to pre-approve Doxil. You say that this drug is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet step therapy criteria. 
 
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 Doxil. Our reviewer says that the 
requested drug does not meet step therapy requirements. Our physician reviewer found the case file does not 
contain documentation of a trial of the preferred step therapy drugs. In addition, there is no evidence presented 
that the preferred step therapy drugs would be less effective, and/or would likely have adverse effects for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Doxil have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Doxil (doxorubicin liposomal).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra battery pack. 
 
You asked the Plan to pre-approve an extra battery. The Plan denied your request. The Plan says the approved 
portable oxygen concentrator includes a battery. 
 
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 the approved portable oxygen concentrator includes a batter. The approved item serves the 
same purpose as the requested extra battery. Therefore, we decided that the Plan does not have to pre-approve 
an extra battery pack.
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 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 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on December 20, 2020, with aspiration pneumonia. Her hospital course was 
complicated by acute respiratory failure requiring mechanical ventilation. She underwent a tracheostomy 
placement on January 5, 2021. There is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services. The enrollee does not require services at the LTACH 
that are not available at the acute care hospital where she 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 long-term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 Omeprazole for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contrast material rendered on June 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that all drugs, including Prodrugs, are reported to DME 
MACs by National Drug Code (NDC). 
 
We looked at the file and Medicare rules. The file shows that code Q9958 was not billed with a valid NDC 
number. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the contrast material rendered on June 
11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the request 
is not a covered benefit. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0230) provided on March 12, 2020. 
 
You asked the Plan to pay for the periapical x-ray. You say that your dentist deemed it necessary for you to 
have this x-ray. You say that the dentist then advised you have a consultation with one of his colleagues. You 
say that routine x-rays and what the dentist deems "necessary" should be covered under the plan. You also say 
that you cannot afford this bill as you lost your job because of Covid-19. The Plan denied your request. The 
Plan says the periapical x-ray is not listed as a covered service. 
 
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 pay for the 
periapical x-ray (D0230) provided on March 12, 2020.