Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the enrollee needs this. The Plan denied your 
request. The Plan says a repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat ESI. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found there are no recent clinical notes 
for this enrollee since the office visit note from September 24, 2021. The reviewer found that the enrollee did 
not want to pursue any surgery or surgical evaluation. The reviewer found that the provider was contacted for additional information and there is no further information available. Therefore, the reviewer found that a repeat 
ESI 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496.  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 70450 billed for date of service August 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on February 22, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. The Plan 
denied your request. The Plan says non-emergency transportation is covered when it is the only way to safely 
and adequately transport an enrollee, or if other means of transporting an enrollee are unsafe due to a medical 
condition. The Plan also says this claim does not meet these requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation via ambulance from the emergency 
department to the enrollees residence was not medically necessary. Our physician reviewer found the enrollee 
did not require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Our reviewer found that transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollees condition. Our physician 
reviewer also found that a prudent layperson would not believe that immediate medical attention was required 
for someone who was being discharged from the emergency department. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on February 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee's groin is still severely swollen and does 
need an intensive plan from a urologist to be released. The Plan denied your request. The Plan says this is not 
medically necessary. 
 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 that the enrollee no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a 
lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient telehealth services provided from August 9, 
2022, through August 11, 2022, billed with the modifier -GQ. 
 
You asked the Plan to pay for the services as billed. You say that you found information on the Plan's website 
that indicates that all plans offered include coverage for asynchronous telehealth services. The Plan denied your 
request. The Plan says this is only covered using modifier -GQ for services in Alaska and Hawaii. 
 
The Plan must follow Medicare rules. Medicare rules say that asynchronous store and forward technology, 
billed with modifier -GQ, is permitted only in federal telemedicine demonstration programs in Alaska or 
Hawaii. 
 We looked at the file and Medicare rules. We find that the information on the website noted in your appeal 
does not indicate that all plans cover asynchronous telehealth services, only that all patients are eligible for 
telehealth services. As Medicare does not cover this type of telehealth outside of Alaska and Hawaii 
demonstration programs, we find that the rules for coverage of the services at issue have not been met. 
 Therefore, we decided that the Plan does not have to pay for the inpatient telehealth services provided from 
August 9, 2022, through August 11, 2022, billed with the modifier -GQ.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors and privacy flap. 
 
You asked the Plan to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors and privacy flap. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that you are independent in feeding. Your 
upper extremity strength and function are adequate to control the power options using their own switches 
which are included in the allowance of the approved power options. The requested privacy flap is used for 
aesthetic purposes and does not serve a purpose that is primarily medical in nature. Based on this information, 
we decided that Medicare rules for coverage of electronic connection between wheelchair controller and two or 
more power seating system motors and privacy flap have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors and privacy flap.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 dental extractions and associated alveoloplasty to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain. You say that you are 
worried your health is at risk and could be fatal without this surgery. The Plan denied your request. The Plan 
says the requested services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, the requested extractions and associated alveoloplasty are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pre-approve 18 dental extractions and associated alveoloplasty to be 
provided by an out-of-network provider.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
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 the provided records do not explain what care services will be provided in the 
LTACH that not available in the present hospital setting. Continued care in the acute hospital is appropriate 
until the enrollee is stable to transfer to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the appropriate level of care 
to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says criteria for admission 
to the LTACH have not been met. 
 
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 the documentation does not support that the enrollee has need for complex 
medical treatment in an LTACH. The enrollee does not require services at the LTACH that are not available at 
the acute care hospital or the skilled nursing facility. The requested treatments are not medically necessary at 
the LTACH level of care. The enrollee is noted to have a poor overall prognosis and requires services at an 
acute care hospital. The enrollee can receive further care at the current acute care hospital or a lower level of 
care when deemed appropriate.  
 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick catheter system and supplies (K1006, 
A9270). 
 
You asked the Plan to pre-approve a Purewick catheter system and supplies. You say that the enrollee gets 
frequent urinary tract infections, and this could prevent doctor's visits. The requested items are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the request is not approved because the 
requested supplies are available with standard pouch type female external collection devices from an in-
network provider. There is no clinical information submitted with this showing that the enrollee is not able to 
use a standard female external collection device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The requested device is not a covered item with the Plan. Based on 
this information, we decided that Medicare rules for coverage of a Purewick catheter system and supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Purewick catheter system and 
supplies (K1006, A9270).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Retacrit or Procrit. 
 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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed one of the preferred drugs. The reviewer found that there is no 
documentation provided indicating that the plans required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are paralyzed 
completely on the left side and cannot use a regular wheelchair. The Plan denied your request. The Plan says 
you do not meet criteria for the requested device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  The file does not show that you have been evaluated by a physical or occupational therapist. In addition, the 
documentation does not support that your home provides adequate access between rooms, maneuvering space, 
and surfaces for the operation of the requested power wheelchair. This means that Medicare rules for coverage 
of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum pump (L5781) and a below knee alignable 
system (L5910). 
 
You asked the Plan to pre-approve the requested services. You say that the vacuum system reduces shear forces 
and prevents skin breakdown, and an alignable system promotes stability and safety. The Plan denied your 
request. The Plan says the alignable system is not medically necessary, and the vacuum pump as experimental. 
 
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 a previous bilateral below-the knee amputation who is requesting 
authorization for upgraded components for a lower extremity prosthesis. In this case, the enrollee has had a 
recent replacement socket. The requested alignable system has not been shown to be superior to other standard 
treatments for the medical condition. The requested vacuum pump for the prosthesis 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vacuum pump (L5781) and a below knee alignable system (L5910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the segmental pneumatic appliance for use with 
pneumatic compressor, trunk (E0656). 
 
You asked the Plan to pre-approve the segmental pneumatic appliance. You say that the item is medically 
necessary. The Plan denied your request. The Plan says a segmental pneumatic appliance for use with 
pneumatic compressor, trunk is not medically necessary since criteria for the pneumatic compressor device was 
not met as outlined, the requested appliance being appealed is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if the base PCD is not covered, related 
accessories are not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the segmental pneumatic appliance have not been met. Specifically, the base PCD was denied and 
therefore, the related accessory is not medically necessary. Therefore, we decided that the Plan does not have to 
pre-approve the segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve injections. You say that the requested injections are medically necessary for 
the enrollee. The Plan denied your request. The Plan says the provider needs to contact the enrollees new Plan 
carrier to request the service as the enrollee is no longer covered under Aetna as of January 01, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that this appeal was received after the enrollees 
termination date; therefore, the enrollee is not eligible for coverage. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs and outpatient hospital services 
provided from August 5, 2022, to August 12, 2022. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says the 
self-administered drugs do not fall under the covered services. 
 
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 pay for the self-administered drugs and 
outpatient hospital services provided from August 5, 2022, to August 12, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.