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

We decided that the Plan has to pre-approve a semi-electric hospital bed (E0261). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the bed is medically necessary. 
The Plan denied your request. The Plan says that coverage criteria are not met. 
 
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 hospital bed is medically necessary. Our physician reviewer found the medical records 
indicate that the enrollee requires several position changes throughout her sleep due to her chronic back pain. 
In addition, she is at significant fall risk when getting in and out of bed due to the height of standard beds and 
inability to adjust the height. 
 
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 been met. Therefore, we decided that the 
Plan has to pre-approve a semi-electric hospital bed (E0261).  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right knee radiofrequency ablation (RFA) (64624). 
 
You asked the Plan to pre-approve right knee RFA. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 right knee RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental/investigational and is the subject of on-going clinical 
trials. Therefore, the request is considered 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 right knee RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right knee radiofrequency ablation (RFA) (64624).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the breast (77049). 
 
You asked the Plan to pre-approve an MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a biopsy is more appropriate. 
 
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 an MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found the records show the the 
enrollee has an abnormality with a personal history of breast cancer. An MRI is recommended for women with 
a personal history breast and dense tissue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the breast (77049).  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation spinal surgery. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation spinal surgery. 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 medically 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 percutaneous vertebral augmentation 
spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records do not show that the fracture is less than six 
weeks old. Also recent literature shows that Kyphoplasty is not effective in treatment of compression fractures. 
More conservative measures are needed. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation spinal surgery have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation spinal 
surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Granix. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has rectal cancer and neutropenia. The documentation does not support that the 
enrollee has tried and failed Neupogen, Nivestym, and Zarxio. The documentation does not outline 
contraindications or reason these medication were not trialed. Therefore, the requested drug 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 Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging Spectroscopy (76390). 
 
You asked the Plan to pre-approve the MRI Spectroscopy. You say that the MRI Spectroscopy is medically 
necessary. The Plan denied your request. The Plan says this type of imaging is not medically necessary. 
 
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 Spectroscopy. Our reviewer 
says that the requested MRI Spectroscopy is not medically necessary. Our physician reviewer found 
spectroscopy distinguishes brain metastases from glioma. It's clear from existing information that the enrollee 
has breast cancer metastases. 
 
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 Spectroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Magnetic Resonance Imaging Spectroscopy (76390).
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 necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires or can tolerate an intensive rehabilitation therapy program 
provided 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) defined by codes 
A4595, E0745, L0650, L3916, L3960, L1851 and L2397 provided to the enrollee on March 25, 2020. 
 
You asked the Plan to pay for the DME. You say that the claims should be paid. The Plan denied your request. 
The Plan says the dates of service on the record reflect a different date of service than the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the durable medical equipment (DME) defined by codes A4595, E0745, L0650, 
L3916, L3960, L1851 and L2397 provided to the enrollee on March 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab). 
 
You asked the Plan to pre-approve the Prolia. You say that the enrollee needs this for treatment of osteoporosis. 
The Plan denied your request. The Plan says this drug is to be picked up at a pharmacy and brought to the 
office for administration. In this scenario, the drug must be covered by a Part D plan. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia (denosumab).  
 
Benefits for the Prolia 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 pay for a TENS unit (E0745) provided to the enrollee on April 26, 
2020. 
 
You asked the Plan to pay for the TENS unit. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a TENS unit (E0745) 
provided to the enrollee on April 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Synvisc. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of Primary osteoarthritis, right shoulder. The enrollee has already 
undergone a series of injections with the most recent series ending on January 21, 2020. The dose and 
frequency of administration should be consistent with the FDA approved labeling. It is expected that a course 
of injections (Synvisc) will not be repeated within six months' time. A repeat series of injections may be 
allowed when: The indications continue to be met; and Significant improvement in pain and functional capacity 
from the prior series of injections is documented in the medical record; and The last injection (in a prior course) 
was given at least six (6) months ago. Repeat injections for shoulder arthritis are limited to a single repeat 
course. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 4 and 5. 
 
You asked the Plan to pre-approve the core build up. You say that there was insufficient tooth structure once 
decay and broken restoration was removed. You also say that a build up and full coverage restoration is 
necessary to restore teeth # 4 and 5. The Plan denied your request. The Plan says core build up is not listed as a 
covered service. The Plan also says if a service is not listed then it is not covered. 
 
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, core build up is not among those 
covered under this benefit. The Evidence of Coverage clearly states that if a dental service is not listed then it is 
not covered. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for teeth 
# 4 and 5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning cushion. 
 
You asked the Plan to pre-approve a positioning cushion. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item 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. 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 positioning cushion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Reader. 
 
You asked the Plan to pre-approve a Freestyle Libre Reader. You say that the item is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices are covered when specific criteria 
are met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre Reader have not been met. Specifically, the enrollee is not on injectable insulin. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve a group 3 power wheelchair. You say that you would like the plan to 
reconsider their denial The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 enrollee has a power wheelchair. The enrollee's current power wheelchair serves the 
same purpose as the requested wheelchair. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) and hospital discharge day 
management; 30 min (99239) provided November 13, 2019 to November 15, 2019. 
 
You asked the Plan to pay for the inpatient hospital services. You say that medical records are attached for 
consideration of claim for hospital stay of 11/13/2019 - 11/15/2019. The Plan denied your request. The Plan 
says incorrect place of service. The billed service is not supported without required documentation. 
 
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 99220 and 99239 are not supported in the medical record. Specifically, for CPT code 
99220 place of service 21 was not the most appropriate place of service performed. The documentation 
submitted does not include a hospital discharge day management note with a recorded duration of time of 31 
minutes or more. The records show that the plan attempted to obtain the needed documentation from the 
provider without success. Based on this information, we decided that Medicare rules for coverage of the 
inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for 
initial observation care (99220) and hospital discharge day management; 30 min (99239) provided November 
13, 2019 to November 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for trunk repair (13101) provided on May 15, 2020. 
 
You asked the Plan to pay for the trunk repair. You say that you would like reconsideration because the 
member had three separate procedures to avoid multiple visits. The Plan denied your request. The Plan says 
CPT 13101 has an MUE value of 1, and the provider billed 3 units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 13101 is 1. You billed 3 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the trunk repair have not been met. Therefore, 
we decided that the Plan does not have to pay for trunk repair (13101) provided on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have accidents and you are unable 
to stand and walk to get to the bathroom. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.