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

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Superion spacer is 
considered experimental/investigational in nature, as more research is needed to show its safety and efficacy. 
The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a lumbar ESI is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
He had a caudal ESI that produced 50 percent pain relief for six weeks. The Medicare criteria require 50 
percent pain improvement for three months from a prior injection. The criteria are not met; therefore, the 
services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the durable medical equipment provided 
on July 1, 2020, August 1, 2020, and September 1, 2020. 
 
You asked the Plan to waive the coinsurance for the durable medical equipment. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received durable medical equipment on the dates of service at 
issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 15% 
coinsurance for Durable medical equipment.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received durable medical 
equipment on July 1, 2020, August 1, 2020, and September 1, 2020. You have been asked to pay a 15% 
coinsurance for the durable medical equipment, totaling $57.61. The durable medical equipment falls within 
the Durable medical equipment benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the durable medical equipment provided on July 1, 2020, August 1, 2020, and September 1, 2020.
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 you disagree with the denial. 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 with intracranial hemorrhage, respiratory failure, heart attack, and new onset atrial 
fibrillation. He is improving but requires only short term additional acute care services which can be safely be 
completed in the current setting. He does not require services at the LTACH that are not already available at 
the current setting. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current setting. The LTACH services are 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 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 a hyaluronan injection. 
 
You asked the Plan to pre-approve hyaluronan. The Plan denied your request. The Plan says there is no 
documentation of a physical exam of the knee or x-ray findings demonstrating osteoarthritis. 
 
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 hyaluronan. Our physician reviewer 
found that the enrollee is noted to have chronic pain, including in his back and knees. A formal knee 
examination is not documented. X-ray reports of the knees are not reported or submitted for review. While the 
enrollee is noted to take oral pain medication, what medications he has specifically taken for his knees and how 
he has responded to them is not documented. How the enrollee has responded to corticosteroid injections is not 
documented. There is no evidence that the enrollee has seen physical therapy, occupational therapy, or an 
orthopedist. As such, the requested hyaluronic acid injections are not shown to be currently medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyaluronan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hyaluronan injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an infusion pump. 
 
You asked the Plan to pre-approve these 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. Medicare rules say that an infusion pump is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
He had a successful trial of intrathecal opiates. He has a pacemaker in place. The Medicare rules state that an 
infusion pump is contraindicated with other implanted programmable devices; therefore, the criteria are not 
met, and the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an infusion pump.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for excision of open wounds (15002 and 15003) provided on 
November 25, 2019. 
 
You asked the Plan to pay for excision of open wounds. You say that these codes are supported. The Plan 
denied your request. The Plan says these codes were not documented in the operative report. 
 
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 15002 is  surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. The definition of  
15003 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar 
(including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 
sq cm, or part thereof, or each additional 1% of body area of infants and children (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 excision of open wounds. Our reviewer says 
that these codes are not supported. Our physician reviewer found CPT codes 15002 and CPT 15003 cannot be 
verified if performed as a separate procedure.  Debridement would not be reported separately when wound 
requires debridement of non-viable 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 excision of open wounds have not been met. Therefore, we decided that the 
Plan does not have to pay for excision of open wounds (15002 and 15003) provided on November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda 
 
You asked the Plan to pre-approve Keytruda. You say that the clinical information provided shows that the 
requested drug is prudent and necessary to better maintain the enrollee's health. You say that the drug is 
medically necessary and should not be denied based on the economics of the health plan. Keytruda is only 
approved for use as a single agent. The Plan denied your request. The Plan says the enrollee does not meet the 
clinical criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested drug is not FDA approved 
for the enrollee's diagnosis when being used in combination therapy. The records show that the enrollee is 
planning to have radiation in combination with carboplatin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a non-network dermatologist. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 
a referral to a non-network dermatologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the maxillary partial denture (D5213) and mandibular 
partial denture (D5214). 

You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that 
these services are medically necessary because your current dentures do not fit properly. The Plan denied your 
request. The Plan says you have exhausted your benefit limit for the services requested. 
 
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 maxillary 
partial denture and mandibular partial denture once every five years.  
 
We looked at the file and Medicare rules. The file indicates that you received these services in November 2017 
and have exhausted your benefits until 2022. Based on this information, we decided that the Plan's rules for 
coverage of the maxillary partial denture and mandibular partial denture have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the maxillary partial denture (D5213) and mandibular 
partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not been appropriately evaluated for this request. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found there is no clear 
documentation that you have a personal mobility deficit that impairs participation in MRADLs such as 
toileting, feeding, grooming and bathing in customary locations within the home. The records indicate the 
power scooter is required to assist ambulation to get to doctor's appointments. There is no documentation that 
you could safely operate a power mobility device. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Orthosis. 
 
You asked the Plan to pre-approve the MyoPro Orthosis. You say that you would like reconsideration because 
this equipment is medically necessary. The Plan denied your request. The Plan says the MyoPro Orthosis is not 
known to be effective, based on scientific evidence, professional standards, and expert opinion, in improving 
health outcomes. 
 
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 MyoPro Orthosis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature in the peer reviewed publications to assess safety, 
efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper 
extremity paralysis/paresis from conditions such as the member's brachial plexus injury, or other  
neuromuscular/neurological disease or injury. 
 
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 MyoPro Orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro Orthosis.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colorectal screening test. 
 
You asked the Plan to pre-approve a colorectal screening test (81528). You say that you need this test The Plan 
denied your request. The Plan says you have symptoms so you do not meet criteria for the test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
 
 
 
 
 
 
 
 
The record shows you have symptoms and therefore do not meet criteria. Therefore, we decided that the Plan 
does not have to pre-approve a colorectal screening test.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight assay testing provided on July 13, 2020. 
 
You asked the Plan to pay for GeneSight testing. You say that this testing was medically necessary and is 
covered by Medicare. The Plan denied your request. The Plan says the denial of payment for this testing is 
correct, because this testing was ordered by a non-physician family medicine practitioner. 
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight assay testing is only covered when 
ordered by a licensed psychiatrist or neuropsychiatrist contemplating an alteration in neuropsychiatric 
medication.  
 
We looked at the file and Medicare rules. This testing was not ordered by a licensed psychiatrist or 
neuropsychiatrist. Based on this information, we decided that Medicare rules for coverage of GeneSight testing 
have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight assay testing 
provided on July 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral injections at a second level for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says no more than two transforaminal injections may be performed at a single setting. 
 
The rules say that no more than two transforaminal injections may be performed at a single setting (e.g. single 
level bilaterally or two levels unilaterally). 
 
The additional level of injection cannot be covered. Based on this information, we decided that Medicare rules 
for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pre-
approve bilateral injections at a second level for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided on February 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the claim was 
submitted with the incorrect taxonomy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The code in question is a payable code for physician services. There is no 
evidence that the provider does not meet the definition of an NP and she has a valid NPI number. No evidence 
is provided to show that the services were provided outside the scope of the NP's State license. The Plan has 
not provided any evidence to support that this provider cannot be paid for the services at issue. Additionally, 
the taxonomy portion of the claim form is not required for claims processing, and is only used for informational 
purposes. As the taxonomy line on the claim form is not required, an incorrect taxonomy is not grounds for 
denial. Therefore, we decided that the Plan has to pay for the services provided on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair. 
 
You asked the Plan to pre-approve a Group 2 heavy duty power wheelchair. You say that you need a Group 2 
heavy duty power wheelchair. The Plan denied your request. The Plan says your records show no reason or 
order for the power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your 
condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD 
being requested. There is no physician order or face-to-face documentation. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Group 2 heavy duty power wheelchair.