Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you cannot drive and are in need of 
25 round trip rides. The Plan denied your request. The Plan says your appeal request for transportation service 
beyond the number of trips covered in your transportation benefit has been denied. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The record shows that as of September 9, 
2022, you had used 45 trips of your transportation benefit, and still had 5 trips remaining before your 
transportation benefit is exhausted. Based on this information, we decided that you have, or will have, 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional transportation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care for your medical condition. The 
Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are a 71-year-old male with chest pain, syncope and shortness of breath who 
underwent transcatheter aortic valve replacement. In this case, there are no identifiable skilled nursing service 
needs and no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services 
on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that you have knee pain, 
and the next step is knee replacement surgery without this procedure. The Plan denied your request. The Plan 
says genicular nerve radiofrequency ablation is not considered reasonable and necessary in the setting of 
chronic knee pain. 
 
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 genicular nerve radiofrequency 
ablation. 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 to support the medical 
necessity and reasonableness of the requested procedure for the treatment of knee pain.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary for this patient's chronic low back pain due to degenerative disc disease. The Plan denied your 
request. The Plan says the Intracept procedure is considered experimental/investigational and is therefore non-
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is considered experimental at this time and more research is 
needed before it can be determined to be 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transoral outlet reduction endoscopy (TORe) 
procedure. 
 
You asked the Plan to pre-approve the requested services. You say that you need this surgery to continue a 
healthy life. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the TORe procedure employs an endoscopic suturing device to plicate and reduce the size 
of the gastrojejunal anastomosis. While TORe is technically feasible and potentially promising in this case, it 
places you at an unnecessary risk for endoscopic and sedation complications as well as significant incidence of 
post-procedure abdominal pain. No data was presented that you have failed a conservative approach with your 
provider's first recommendations of exercise, diet modification, and pharmacotherapy to otherwise warrant the 
risks of TORe at this juncture. Therefore, the request is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transoral outlet reduction endoscopy (TORe) procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested Botox is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that Botox is medically reasonable or necessary. Our physician reviewer found 
the enrollee has overactive bladder with urge incontinence.  The record does not document that the enrollee has 
had an inadequate response to or are intolerant of an anticholinergic medication. Therefore, the enrollee does 
not meet criteria for Botox. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasal radiofrequency ablation with the VivAer stylus. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure is associated with stable 
and lasting improvement in symptoms. The Plan denied your request. The Plan says there are not enough 
studies to show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has nasal obstruction from inferior turbinate hypertrophy, nasal valve stenosis, 
and nasal sphenoid hypertrophy. There is insufficient literature to support the safety and efficacy of the 
requested service for the enrollee's specific conditions. The record does not establish the medical necessity and 
reasonableness, as defined by Medicare rules. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nasal radiofrequency ablation with the VivAer stylus.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman device. 
 
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 Minuteman device is 
considered experimental in nature. 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 Minuteman device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral replacement sockets, below knee, molded to 
patient model (L5700) and 
additions, to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve bilateral replacement sockets. You say that the items are medically 
necessary. The Plan denied your request. The Plan says items must be obtained through an in-network provider. 
 
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 
bilateral replacement sockets, below knee, molded to patient model (L5700) and 
additions, to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent before your hospitalization, 
and you will not get the therapy you need in a nursing home. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88334 billed for date of service April 19, 
2022. 
 
You asked the Plan to pay for procedure code 88334. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 88334 is bundled into payment for code 88173. 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, we have confirmed that code 88334 
is a column II code to column I code 88173. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88334 billed for date of service April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
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 electrical nerve stimulation 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 back pain and 
morbid obesity. The note dated March 2, 2022 states imaging of the spine was concerning for non-union of 
lumbar fusion and a diagnosis of lumbar adjacent segment disease with spondylolisthesis. She tried physical 
therapy for three months from July to October of 2022 without success. She has surgical issues that have not 
been addressed. The criteria for coverage are not met and 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 spinal cord stimulator (SCS) trial.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. The Plan denied your request. The Plan says this 
appeal for Ondansetron does not meets Medicare criteria for coverage 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 Ondansetron tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve greater than 10 fractions of intensity modulated 
radiation therapy (IMRT). 
 
You asked the Plan to pre-approve 20 fractions of IMRT. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 20 fractions of IMRT. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the delivery of greater than 10 fractions of radiation in the metastatic setting 
seems outside of the standard of care based on guidelines. The case record does not document the need for 
going outside of the standard of care with respect to number of fractions of treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 20 fractions of IMRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve greater than 10 fractions of IMRT.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy pump. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has advanced bone on bone 
arthritis. The Plan denied your request. The Plan says the clinical effectiveness in the setting of shoulder 
arthroplasty has not been demonstrated. 
 
The Plan follows Medicare rules. Medicare rules say that negative pressure wound therapy pumps are only 
covered under certain medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee is being treated for a rotator cuff tear or a rupture of right shoulder. There is 
limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective 
and/or safe treatment for the noted pathology. The studies do not indicate any significant outcome changes with 
the addition of negative pressure wound therapy in the post-operative period. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested negative pressure wound therapy pumps for the approved shoulder replacement 
surgery is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a negative pressure wound therapy pump.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allergy/clinical immunologic service (95199). 
 
You asked the Plan to pre-approve an allergy/clinical immunologic service. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an allergy/clinical immunologic service have been met. No medical records were submitted. Therefore, we decided that the Plan does not have 
to pre-approve an allergy/clinical immunologic service (95199).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wearable defibrillator (K0606). 
 
You asked the Plan to pre-approve a wearable defibrillator. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that a wearable defibrillator (K0606) is covered for 
beneficiaries if they meet one of the criteria listed in the Medicare rules section of this letter. 
 
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 wearable defibrillator. Our reviewer 
says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer 
found that the recent medical records indicate that an internal defibrillator was implanted earlier in 2022. As 
such, it would not appear that the enrollee is a candidate for a wearable defibrillator according to current guidelines. 
 
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 wearable defibrillator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a wearable defibrillator (K0606).