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

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (E2377, E2313, E1007, 
E2311) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says there will not be a need for multiple controls through the joystick. 
 
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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that the enrollee requires other types of proportional input 
devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-
proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more 
powered seating actuators through the drive control, a  separate display (i.e., for alternate control devices),other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee's functional status indicates she would have the ability to control 
any power options through their own individual switches. The E1007 exceeds her medical need and is not 
medically necessary as the patient can independently weight shift and does not require this feature for pressure 
relief. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (E2377, E2313, E1007, E2311) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary interim partial denture (D5820). 
 
You asked the Plan to pre-approve the maxillary interim partial denture. You say that the enrollee will need a 
replacement of their prosthetic because tooth #8 will be missing. The Plan denied your request. The Plan says 
this service 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, 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 a 
maxillary interim partial denture (D5820).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy visits. 
 
You asked the Plan to pre-approve the twelve (12) additional physical therapy visits. The Plan denied your 
request. The Plan says the clinical documentation fails to verify progressive functional improvement in a 
reasonable period. The notes do not show that the expectation that improvement is attainable in a reasonable 
and predicable period of time. The records do not show that unique skills of physical therapy are required to 
safely and effectively provide treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 twelve (12) additional physical 
therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to 
prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy 
is not generally accepted as specific and effective therapy for the patient?s condition. His most recent Neck 
Disability Index score does not reveal significant improvements from prior therapy. You have had extensive 
therapy for this condition and the documentation indicates that your functional level does not appear to require 
the unique skills of a professional therapist to safely and effectively provide treatment. The services do not 
need to be safely and effectively performed only by a therapist or under the supervision of a therapist. The 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
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 twelve (12) additional physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve twelve (12) additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with accessories. 
 
You asked the Plan to pre-approve the PWC. You say that this PWC is needed due to the enrollee's mobility 
deficit. The Plan denied your request. The Plan says the documentation shows this is mostly needed for use 
outside the home. 
 
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 PWC. Our reviewer says that the 
documentation does not support that the requested PWC is medically necessary. Our physician reviewer found 
the documentation is conflicting between the vendor and physician documentation. The physician progress note 
does not support that the patient has a personal mobility deficit that impairs participation in MRADLs in the 
home. Per the physician progress report on 5/20/20, the patient has normal gait and station and coordination is 
intact. The document notes that the patient ambulates with a walker. The DME vendor documentation reveals 
the patient can safely maneuver the PWC but the documentation does not support that this is 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 PWC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Group 3 power wheelchair (PWC) with accessories.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fifteen (15) additional services performed by a qualified 
physical therapist in the home health or hospice setting, each 15 minutes (CPT Code G0151 x 15). 
 
You asked the Plan to pay for the 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 HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay for fifteen (15) additional services 
performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes (CPT Code 
G0151 x 15).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ophthalmology office visit (99203) to be rendered by 
the out of network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there is an available in-network provider who can render 
the requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an 
ophthalmology office visit (99203) to be rendered by the out of network (OON) provider.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the SI joint fusion. We decided that the Plan does not have to pre-
approve inpatient admission with an out-of-network provider.  
 
You asked the Plan to pre-approve the SI joint fusion. You say that you would like reconsideration because this 
service is medically necessary. The Plan says that there is no documentation in the MD notes demonstrating 
concern for SI joint dysfunction or a complaint of pain to the SI joint, and no findings documented on physical 
exam consistent with SI joint dysfunction. 
 
We decided that the Plan has to pre-approve the SI joint fusion.  
  
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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 SI joint fusion. Our reviewer says 
that a fusion of the SI joint is medically reasonable and necessary. The member has clearly documented SI joint 
dysfunction in the progress notes. He has failed conservative therapy and has had SI joint injections which 
produced 50% pain relief. 
 
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 SI joint fusion have been met. Therefore, we decided that the Plan has to 
pre-approve the SI joint fusion.  
 
We also decided that the Plan does not have to pre-approve inpatient admission with an out-of-network 
provider. 
 
The Plan follows Medicare rules. Medicare rules say that that an inpatient admission is generally appropriate 
when the admitting physician expects the patient to need hospital care that crosses at least two midnights. 
Medicare rules also say that a Medicare plan may restrict members to a network of providers as long as 
medically necessary covered care is accessible and available through this network. 
 
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 inpatient admission with an out-of-
network provider. Our physician reviewer found SI joint fusion surgery is typically an outpatient procedure, 
where patients are discharged within a day. There are no unstable medical conditions identified that would 
necessitate an inpatient hospital admission for the enrollee in this case. Additionally, there is no indication for 
this member to go out-of-network. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission with an out-of-network provider. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient admission with an out-of-network 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryoneurolysis. 
 
You asked the Plan to pre-approve cryoneurolysis. 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 follows Medicare rules. Medicare rules say that peripheral nerve blocks will be considered medically 
reasonable and necessary when specific criteria is 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 cryoneurolysis. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have bilateral 
knee osteoarthritis. A recent office note discussed stem cell injections, but did not address cryoneurolysis. 
There is no evidence that the requested cryoneurolysis is required as a diagnostic tool, to perform a procedure 
or to circumvent analgesic allergies. Cryoneurolysis is not curative of osteoarthritis. As such, the 
documentation does not support that the requested procedure is 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 cryoneurolysis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cryoneurolysis.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane, Carboplatin, Aloxi, Dexamethasone, and 
Emend. 
 
You asked the Plan to pre-approve Abraxane, Carboplatin, Aloxi, Dexamethasone, and Emend. You say that 
the medications are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria for a step therapy exception has not been met. 
 
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 Abraxane, Carboplatin, Aloxi, 
Dexamethasone, and Emend. Our reviewer says that the medications are not medically necessary. Our 
physician reviewer found the documentation does not support that Taxol (paclitaxel) or Taxotere (docetaxel) 
would likely 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 Abraxane, Carboplatin, Aloxi, Dexamethasone, and Emend have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Abraxane, Carboplatin, Aloxi, 
Dexamethasone, and Emend.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI of the abdomen (74181). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because you have 
been experiencing abdominal pain and weight loss. The Plan denied your request. The Plan says that clinical 
information submitted does not evidence that you suffer from any of the indicated conditions. 
 
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. Our reviewer says that this 
MRI is being ordered after a thorough workup has been undertaken with computed tomography and ultrasound 
and endoscopy without diagnosis. Our physician reviewer found due to ongoing symptoms and thorough prior 
workup, the MRI is medically reasonable and 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI of the abdomen (74181).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for 
lymphedema assessment(s) (CPT Code 93702). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the testing is experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found among patients who have undergone complete axillary node dissection, in one review, 
lymphedema developed in 23 percent when measured using limb volume and 45 percent using bioimpedance 
spectroscopy criteria. As this patient underwent a full axillary dissection use of bioimpedance spectroscopy is 
reasonable and 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 service have been met. Therefore, we decided that the Plan has to pre-
approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) (CPT 
Code 93702).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace (L1852). 
 
You asked the Plan to pre-approve a knee brace. 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 follows Medicare rules. Medicare rules say that a knee immobilizer without joints, or a knee orthosis 
with adjustable knee joints, or a knee orthosis, with an adjustable flexion and extension joint that provides both 
medial-lateral and rotation control, are covered if the beneficiary has had recent injury to or a surgical 
procedure on the knee(s). 
 
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 a knee brace. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found the L1852 knee orthosis, with an adjustable 
flexion and extension joint that provides both medial-lateral and rotation control is not medically necessary as 
the enrollee has not had recent injury to or a surgical procedure on the knee(s). There is no evidence of 
instability on a physical exam that requires medial-lateral and rotation control. The documentation does not 
indicate the coverage criteria have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a knee brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee brace (L1852).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #10 (D2750). 
 
You asked the Plan to pre-approve a crown for tooth #10. 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 a crown for tooth #10. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the tooth required endodontic treatment which was performed. The provided x-ray 
which is of poor quality seems to reveal a tooth broken down to at least the gum line if not to the osseous crest. 
From what can be ascertained from the provided x-ray, it appears there is insufficient structure available to 
place a ferrule on the tooth which is a necessary structural design that provides stability and retention for a 
crown, particularly when there is no remaining coronal structure. With the minimum amount of remaining 
tooth structure and the proximity of the bone, it does not appear there is sufficient tooth structure to properly 
place a crown. Given the radiographic presentation, there is no method of properly placing a crown without 
removing bone around the remaining tooth first to get access to solid root structure. As it stands, there is 
insufficient structure to properly restore tooth #10 as requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a crown for tooth #10 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown for tooth #10 (D2750).