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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0652) and a 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and a pneumatic appliance. You say that 
this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage 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. PCD related accessories are eligible for 
reimbursement only when the appropriate, related base PCD meets the applicable coverage criteria for that type 
of PCD. 
 
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. Because the requirements for the base PCD are not met, the accessory is also not covered. Therefore, 
we decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0652) and a 
pneumatic appliance (E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service September 
14, 2022. 
 You asked the Plan to pay for procedure code 85060. You say that this service was billed with an appropriate 
place of service code. The Plan denied your request. The Plan says this service was not billed in accordance 
with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was 
furnished to an enrollee in an outpatient hospital (Place of Service code 22) setting. Therefore, we decided that 
the Plan does not have to pay for procedure code 85060 billed for date of service September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that testing confirms the enrollee has COPD and 
chronic respiratory with an elevated CO2 and bicarbonate. The provider clearly documented the need for NIV 
to treat the enrollee's diagnosis. All chart notes and testing is included. The Plan denied your request. The Plan 
says the request for a home mechanical ventilator set in TTV-VAPS mode that could be delivered by BiPAP is 
not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD and a 
history of HFrEF. The enrollee was hospitalized in September 2022, and a venous blood gas showed a PCO2 of 
60.  During a prior hospitalization for a fentanyl overdose, an arterial blood gas showed very mild CO2 
retention, with PA CO2 of 47 and pH of 7.32.  There is no ABG done while stable to document chronic CO2 
retention. If this enrollee does have chronic CO2 retention, she may benefit from BiPAP with AVAPS during 
sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the services requested are not 
medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a crown is often considered where 
there is substantial missing tooth structure.  In this case, both teeth do not have more than a one surface existing 
restoration, and there are no carious lesions seen on any other surfaces.  There are no damaged cusps seen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary in this case. Our physician reviewer 
found this 59-year-old enrollee has chronic low back pain. The enrollee has tried physical therapy, rest, activity 
modification and nonsteroidal anti-inflammatory drugs (NSAIDs). The enrollees magnetic resonance imaging 
shows severe stenosis at L5-S1 as well as multi-level degenerative disc disease and facet arthropathy. On 
December 6, 2022, the enrollee underwent an epidural steroid injection which gave 100% pain relief for 3.5 
weeks. The Medicare LCD criteria is 50% pain relief for 3 months. This time period has not elapsed yet. 
Therefore, the request is deemed not 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 Sensor, receiver, and transmitter. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 enrollee does not use insulin, does not have a pump and there are 
no documented vision or dexterity problems that would prevent the use of a regular glucometer. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Dexcom G6 Sensor, receiver, and transmitter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 2 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the group 2 power wheelchair and accessories. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the requested power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare will pay for durable medical equipment that 
is needed for use in the home. 
 
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 group 2 power wheelchair and 
accessories. Our reviewer says that the documentation submitted does not support that a power wheelchair is 
required to accomplish mobility related self-care tasks in the home. Our physician reviewer found the 
documentation indicates the power wheelchair is to improve mobility in the community. 
 
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 group 2 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the group 2 power wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Blepharoplasty of the lower lid (15821) provided March 14, 
2022. 
 
You asked the Plan to pay for the surgical procedure. You say that the appearance of your eyes and your 
sensitivity to that condition was largely responsible for the mental health related suffering you endured. The 
Plan denied your request. The Plan says cosmetic eyelid procedures are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay 
for Blepharoplasty of the lower lid (15821) provided March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307) provided on June 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (80307) provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the RFA, nerves innervating the sacroiliac (SI) joint, 
with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625). 
 
You asked the Plan to pre-approve the RFA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says this procedure is not covered because it is considered to be investigational. The 
Plan states there is not enough high-quality evidence that shows this procedure is as helpful and as safe as other 
standard treatments. 
 
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 RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/ investigational procedure because of the wide variation in 
efficacy reported in the literature. Therefore, the request is deemed not 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve the RFA, nerves innervating the sacroiliac (SI) joint, with image guidance (ie, fluoroscopy or 
computed tomography) (CPT code 64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ostomy belt with peristomal hernia support (A4396). 
 
You asked the Plan to pre-approve an ostomy belt with peristomal hernia support. You say that the requested 
item is a medical necessity for you. The Plan denied your request. The Plan says the requested item is not a 
covered benefit in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that ostomy supplies are appropriately used for 
colostomies, ileostomies or urinary ostomies. Use for other conditions will be denied as noncovered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an ostomy belt with peristomal hernia support have not been met. Specifically, the case record does 
not support that the requested item is to be used for a colostomy, ileostomy or urinary ostomy. Therefore, we 
decided that the Plan does not have to pre-approve an ostomy belt with peristomal hernia support (A4396).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for an ephedrine hydrochloride injection, for intravenous use (code J3490) 
provided on July 6, 2022. 
 
You asked the Plan to pay for the ephedrine hydrochloride injection, for intravenous use. You say that the 
medical records submitted support the medical necessity. The Plan denied your request. The Plan says that the 
Plan requires medical records. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule or a Plan rule based on 
the additional medical records provided to substantiate the denial. Therefore, we decided that the Plan has to 
pay for an ephedrine hydrochloride injection, for intravenous use (code J3490) provided on July 6, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer 750 units every week for two visits. 
 
You asked the Plan to pre-approve Injectafer. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that the enrollee has tried 
and failed Ferrlecit, Feraheme, Infed, or Venofer. The documentation does not support that Ferrlecit, Feraheme, 
Infed, or Venofer would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, 
the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer 750 units every week for two visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power assist device for a manual wheelchair (E0986). 
 
You asked the Plan to pre-approve the power assist device for a manual wheelchair. You say that this item is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. The 
enrollee already has equipment to service this purpose. 
 
The Plan must follow Medicare rules. The rules 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 file shows that you have a power wheelchair. The power wheelchair serves the same purpose as the power 
assist device for the manual wheelchair. "Backup" items or items for use outside the home are non-covered. 
Therefore, we decided that the Plan does not have to pre-approve a power assist device for a manual wheelchair 
(E0986).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for drugs (J2469) provided on March 24, 2022. 
 
You asked the Plan to pay for the drugs. You say that this service was medically necessary. The Plan denied 
your request. The Plan says that the code billed is included in another procedure billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan did not provide documentation of the procedure codes billed. Without 
this information, it cannot be determined if the code billed is included in another service. The plan did not cite 
the rule or regulation used to make their determination. Therefore, we decided that the Plan has to pay for drugs 
(J2469) provided on March 24, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 4MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Ondansetron 4MG tablet is a self-administered drug and does not fall under 
Part B coverage. 
 
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 4MG tablet.   
Benefits for the medication 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 pay for the initial hospital care (99223) and diagnostic laparoscopy 
(47563) provided August 14, 2022. 
 
You asked the Plan to pay for the hospital services. You say that you received a denial of the claim due to no 
medical records received. You are attaching the requested records along with a copy of the Explanation of 
Payment. The Plan denied your request. The Plan says the documents provided do not support level of care and 
code not appropriate for service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: a comprehensive history, a 
comprehensive examination, and medical decision making of high complexity. The CPT Code Manual 
definition of code 47563 is diagnostic laparoscopy and surgical removal of the gallbladder with the additional 
work of an intraoperative cholangiography.  
We asked our coder 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 hospital services. Our reviewer says that the criteria for 
Medicare coverage were not met. Our reviewer found the documentation submitted was reviewed and does not 
meet criteria. The evaluation and management procedure provided does not support level of service 99233. Per 
CPT guidelines 3 of 3 key components must be met or exceeded, in this case: History - expanded problem 
focused; Exam - expanded problem focused; Medical decision making - high complexity. There is a more 
appropriate code to report for service provided. For CPT 47563, the operative report does not include 
documentation of cholecystectomy with cholangiography and therefore this procedure cannot be verified. The 
procedure report supports that laparoscopy, surgical; cholecystectomy was performed. There is a more 
appropriate code to report for service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan 
does not have to pay for the initial hospital care (99223) and diagnostic laparoscopy (47563) provided August 
14, 2022.