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

 
We decided that the Plan does not have to pre-approve a computed tomography (CT), abdomen (74150). 
 
You asked the Plan to pre-approve the abdominal CT. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT. Our reviewer says that the 
requested abdominal CT is not medically necessary. Our physician reviewer found the documentation indicates 
the enrollee is experiencing upper quadrant and lower quadrant pain. The reviewer found that an abdominal CT 
is not appropriate in this case as the field of view would not cover the entirety of the problem areas. Therefore, 
the reviewer found that the requested abdominal CT is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a computed tomography (CT), abdomen (74150).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan does not have to pre-approve Zometa. 
 
You asked the Plan to pre-approve Zometa. The Plan denied your request. The Plan says this drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zometa. Our reviewer says that Zometa 
is medically reasonable and necessary in this case. Our physician reviewer found that the Medicare approved 
drug compendium, DrugDex contains a supportive citation for the use of the requested drug in the enrollee's 
clinical situation stating: "there were borderline significant reductions in distant recurrence and breast cancer 
mortality in a large meta-analyses of bisphosphonate use in women with early breast cancer. In another large 
systematic review and meta-analysis, adjuvant zoledronic acid therapy significantly reduced the risk of death 
and the risk of fracture compared with non-use, placebo, or delayed use. The elements of the coverage criteria 
are satisfied.  The requested drug 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 Zometa have been met. Therefore, we decided that the Plan does not have to 
pre-approve Zometa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99140 and 99109 billed for date of service 
December 6, 2021. 
 You asked the Plan to pay for procedure codes 99140 and 99109. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says procedure codes 99140 and 99109 are 
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 codes 99140 and 99109 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99140 and 99109 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99140 and 99109 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99140 and 99109 billed for date of service 
December 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission provided from January 19, 2021, to 
January 25, 2021. 
 
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the 
provider had 1 year to submit the claim but failed to submit the claim within the filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient admission was not filed until May 27, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for an inpatient admission provided from January 19, 2021, to 
January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter crutch substitute. 
 
You asked the Plan to pre-approve a knee scooter crutch substitute. You say that this item is necessary for your 
condition. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these 
crutch substitutes. Based on this information, we decided that Medicare rules for coverage of a knee scooter 
crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee 
scooter crutch substitute.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter. 
 
You asked the Plan to pre-approve a motorized scooter. You say that you need the scooter and want to get out 
to go to church. The Plan denied your request. The Plan says if any power operated vehicle or power 
wheelchair is only for use outside the home, it will be denied as noncovered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules also say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. The records also show that you received a 
motorized wheelchair in 2018 and a motorized scooter in 2020. A motorized wheelchair and scooter which you 
previously received serve the same purpose as the wheelchair you are requesting. Therefore, we decided that 
the Plan does not have to pre-approve a motorized scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block (MBB) injections (64493, 64494). 
 
You asked the Plan to pre-approve the MBBs. You say that you will do whatever you can to find pain relief. 
You say that the only relief you have is sitting and warm pool therapy. You also say that the pain stands in the 
way of your everyday life. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 MBBs. Our reviewer says that the 
requested MBBs are not medically necessary. Our physician reviewer found the provided documentation 
indicates that you experienced 40 to 60% pain relief after the first injection. Therefore, the reviewer found that 
the requested MBBs 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 MBBs have not been met. Specifically, the file indicates that your pain 
relief was 40 to 60% after the first injection. Therefore, we decided that the Plan does not have to pre-approve 
medial branch block (MBB) injections (64493, 64494).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT scan) provided 
on May 02, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT scan). You say that this is not a 
copayment since this is not an even amount of money. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 $30 
copayment for Diagnostic and therapeutic radiology services. 
 
You have been asked to pay a $30 copayment for computed tomography (CT scan). This item/service falls 
within the Diagnostic and therapeutic radiology services 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. You have been asked to pay $22.24 which is less than the 
standard $30 copayment for the CT scan. Therefore, we decided that the Plan does not have to waive the 
copayment for computed tomography (CT scan) provided on May 02, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient rehabilitation facility (IRF) admission and 
services provided from March 22, 2022, through March 27, 2022. 
 
You asked the Plan to pay for the IRF care. You say that the IRF admission was medically necessary. The Plan 
denied your request. The Plan says you did not meet criteria for coverage of the IRF admission. 
 
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 pay for IRF care. Our reviewer says that the IRF 
care provided was not medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs did not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for chest pain and coronary artery bypass grafting. Your medical problems were stable. You did not 
have complex nursing or rehabilitation needs.  
 
You did not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supported a need for physical and/or 
occupational therapy, there was no documented need for intensive rehabilitation services. Medically necessary 
care could have been provided in a different level of care. 
 
There was not a reasonable expectation that you could have been able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in the IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the IRF care have not been met. Therefore, we decided that the Plan does not 
have to pay for an acute inpatient rehabilitation facility (IRF) admission and services provided from March 22, 
2022, through March 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paring or cutting of benign hyperkeratotic lesion (e.g., corn 
or callus); two (2) to four (4) lesions provided on August 3, 2022. 
 
You asked the Plan to pay for paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); two (2) to 
four (4) lesions. You say that you have had 2 total hip replacements and you are unable to take care of your 
calluses that keep forming on the bottom of your feet so you go every 3 months to the podiatrist, and you 
thought this was covered. The Plan denied your request. The Plan says Medicare criteria are not met as the 
medical record does not indicate that you have a significant systematic disease that necessitates foot care from 
a professional person. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of paring 
or cutting of benign hyperkeratotic lesion (e.g., corn or callus); two (2) to four (4) lesions have not been met. 
Therefore, we decided that the Plan does not have to pay for paring or cutting of benign hyperkeratotic lesion 
(e.g., corn or callus); two (2) to four (4) lesions provided on August 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (a 
diagnostic test to examine the lining of the esophagus, stomach, and first part of the small intestine) provided 
on June 21, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that you do not 
believe a copayment should be assigned for this service. You say it is a preventive service. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
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 $300 
copayment for outpatient hospital visits.  
 You have been asked to pay $300 for outpatient hospital services. This service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayment for an esophagogastroduodenoscopy (a diagnostic 
test to examine the lining of the esophagus, stomach, and first part of the small intestine) provided on June 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the right and left sacroiliac radiofrequency ablation (64625) 
provided from July 26, 2022, to August 16, 2022. 
 
You asked the Plan to pay for the RFA for sacroiliac joint. You say that you would like to stop using pain 
medications. You say that the pain is unrelenting. You also say that the services were medically necessary. The 
Plan denied your request. The Plan says the services you received were 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 pay for the RFA for sacroiliac joint. Our reviewer 
says that the requested RFA for sacroiliac joint are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested services are considered experimental. Therefore, the reviewer 
found that the requested services are 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 RFA for sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pay for the right and left sacroiliac radiofrequency ablation (64625) provided from July 
26, 2022, to August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are not able to manage at home. The 
Plan denied your request. The Plan says an LTACH admission is not medically necessary, and you can safely 
receive this care in another setting. 
 
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 considered medically reasonable and necessary in this case. Our 
physician reviewer found that you are still unstable and should only require short-term additional acute care 
services that can safely be administered at the current facility until more stable for transfer. You do not require 
services at the LTACH that are not already available at the current facility. 
 
   
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable oxygen contents, gaseous, 1 month's supply (E0443) 
provided on May 24, 2022, to June 24, 2022. 
 
You asked the Plan to pay for portable oxygen contents. You say that you disagree with the denial and the 
oxygen equipment should be covered. The Plan denied your request. The Plan says medical necessity not met 
per evidence-based guidelines. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen contents Our reviewer says 
that the service is not medically necessary. Our physician reviewer found provided records do not document an 
arterial PO 2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent (taken at rest, with 
exercise or in sleep) breathing room air. Records do not report an arterial PO 2 of 56-59 mm Hg or an arterial 
blood oxygen saturation of 89 percent with evidence of dependent edema suggesting congestive heart 
failure; pulmonary hypertension or cor pulmonale or erythrocythemia with a hematocrit greater than 56 percent 
or any other covered indication for the requested home oxygen therapy as required by the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 
240.2. The only provided clinical record in this case reports an oxygen saturation of 95% at rest on room 
air. Provided records do not document evidence in this case that leads to the conclusion that supplemental 
oxygen is still medically necessary and 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 portable oxygen contents have not been met. Therefore, we decided that the 
Plan does not have to pay for portable oxygen contents, gaseous, 1 month's supply (E0443) provided on May 
24, 2022, to June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that your doctor 
recommended the CGM and would like the Plan to cover the item. The Plan denied your request. The Plan says 
you do not meet coverage criteria for the requested CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre CGM and supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert alarm system. 
 
You asked the Plan to pre-approve a Life Alert alarm system. You say that this item is necessary. The Plan 
denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules say telephone alert systems are not covered as they are emergency communications 
systems and do not serve a diagnostic or therapeutic purpose. Therefore, we decided that the Plan does not have 
to pre-approve a Life Alert alarm system.