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

 
We decided that the Plan does not have to pay for the lumbar orthosis billed for date of service April 5, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. 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 lumbar orthosis billed for date of service April 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service November 
25, 2021. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service November 25, 2021.
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 are appealing the denial of inpatient 
rehabilitation admission. The Plan denied your request. The Plan says the service requested is not supported 
based on the records we received. Based on the enrollee's records we suggest care in a skilled nursing facility. 
 
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 the enrollee has a past medical history of paraplegia, sacral decubitus ulcer, and 
weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the 
enrollee has 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses billed for date of service April 6, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
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 file shows that a ankle-foot orthosis and soft interface were billed. The record does not contain a valid 
physician order, proof of delivery, or relevant medical records to support medical necessity for the supplies 
provided in this case. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the orthoses billed for date of service April 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa tablet. 
 
You asked the Plan to pre-approve Gemtesa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa tablet.  
 Benefits for Gemtesa 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that indication for coverage is not 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Vertiflex is 
experimental. More research needed. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex device for the enrollee.
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 are appealing the denial of authorization for 
acute inpatient rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about your condition you do not meet the requirements. 
 
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 you were admitted for presyncope, weakness, and aortic stenosis. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical records support 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular repair of infrarenal aorta and/or iliac 
artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection 
(CPT code 34705) and the inpatient hospital admission. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is already scheduled for the 
procedure. You state that waiting thirty (30) days could affect the enrollee's health. The Plan denied your 
request. The Plan says the procedure is not medically necessary, and the related inpatient hospital admission is 
also 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has an abdominal aortic aneurysm less than 5.5 cm in size 
and without rapid recent expansion, in addition to one block claudication due to peripheral vascular disease. 
Physical examination reveals 2+ pulses and no ulcers. The record as provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service at this time. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-
bi-iliac endograft including pre-procedure sizing and device selection (CPT code 34705) and the inpatient 
hospital admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar. 
 
You asked the Plan to pre-approve Vraylar. You say that this is the only medication that has helped the 
enrollee's condition and function at a normal level. The Plan denied your request. The Plan says the requested 
drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part 
D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vraylar.  
 Benefits for Vraylar 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an AuroraZip interspinous device insertion (20930, 
22612, 22840, 63030). 
 
You asked the Plan to pre-approve an AuroraZip interspinous device insertion. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity 
rules have not been met because the requested service is experimental/investigational. 
 
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 an AuroraZip interspinous device 
insertion. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the requested procedure is considered an 
experimental/investigational procedure as there is not enough evidence of efficacy in the peer-reviewed 
literature. 
 
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 AuroraZip interspinous device insertion have not been met. Therefore, we decided that the Plan does not have to pre-approve an AuroraZip interspinous device insertion (20930, 22612, 
22840, 63030).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contact lenses (V2531) and fitting of contact lenses 
(92072). 
 
You asked the Plan to pre-approve the contact lenses and fitting. You say that the enrollee is unable to achieve 
full correction with spectacles. You also say with custom rigid contact lenses, the enrollee will be able to 
achieve fully functional vision in both eyes. The Plan denied your request. The Plan says the contact lenses are 
covered up to the $600 allowance. The Plan also says that the contact lens fitting is not covered by the Plan's 
supplemental vision benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers $600 for non-vendor frames and standard lenses or standard contact lenses. 
 
We looked at the file and the Plan's rules. The Plan will only cover up to $600 for contact lenses and anything 
beyond that cannot be approved. Based on this information, we decided that the Plan's rules for coverage of the 
contact lenses and fitting have not been met. Therefore, we decided that the Plan does not have to pre-approve 
contact lenses (V2531) and fitting of contact lenses (92072).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prolia. 
 
You asked the Plan to pay for Prolia. You say that the enrollee has tried Fosamax and Boniva. You also say 
that the enrollee does have a T12 fracture. The Plan denied your request. The Plan says the enrollee has not 
tried Zoledronic Acid. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 Prolia. have been met. Medical records 
were not provided for this case. Without this information, we are unable to determine if the use of Prolia is 
medically necessary for the enrollee. Therefore, we decided that the Plan does not have to pay for Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this procedure improves the quality of life of 
patients suffering from vertebrogenic low back pain. The Plan denied your request. The Plan says that this is 
considered experimental and investigational. 
 
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 requested services are not considered medically reasonable and necessary in this case. There are multiple 
plausible pathologic sources of significant pain generation. The midline back pain, the noted pain-aggravating 
and pain-relieving factors, and intact neurologic exam are all non-specific to any pathologic entities. Overall, 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on April 6, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation does not support the billed supply codes. 
 
The Plan must follow Medicare rules. The rules state that if the information in the patients medical record does 
not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved. We looked at the file and the rules. The records do not include a condition, prognosis, or limitation, and other 
interventions that would substantiate the use of the orthoses. The record does not contain relevant medical 
records which support medical necessity for the supplies provided in this case. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the orthoses provided on April 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient stay following a right total knee replacement. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the enrollee to have an 
inpatient stay because they have a lot of comorbidities. The Plan denied your request. The Plan says the 
enrollee does not have a health problem that requires hospital care. The Plan also says that this procedure can 
be performed as an outpatient procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
  
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record does not show that the admitting physician reasonably expects that the 
enrollee's necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient stay following a right total knee replacement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage for the 
requested equipment have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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 for a pneumatic compression device. Our reviewer 
says that the enrollee is a 71-year-old female with a past medical history of bilateral lower extremity 
lymphedema secondary to chronic venous insufficiency. A segmented, calibrated pneumatic compression 
device (E0652) has been requested. Our physician reviewer found that, based on the medical records provided, 
the provided records do not clearly document edema extending onto the chest, trunk or abdomen on physical 
examination or failure of at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 
after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and 
successfully uses the appliance provided. Provided records from April 14, 2022, document that the enrollee 
"has not used her pump consistently over the last few weeks." Therefore, the requested criteria for a basic pump 
trial have not been satisfied.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).