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

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair and pressure-reducing 
mattress. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says if appropriate, the doctor can then resubmit for the proper mattress and proper 
wheelchair (using the correct codes) if criteria is 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 the items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a clinical progress note dated 11/22/2022 indicated that the enrollee was evaluated for a refill of 
medications as well as durable medical equipment. On physical examination the enrollee was noted to have 
lower extremity weakness. No edema was noted in the lower extremities. There is limited clinical 
documentation indicating the enrollees level of mobility and function. It is unclear why the enrollee requires a 
high strength lightweight manual wheelchair versus a standard wheelchair for mobility and accomplishing 
activities of daily living. It is also unclear if she can safely operate the manual wheelchair and her home is 
accessible for it. The enrollee is not noted to have a history of skin breakdown or pressure wounds on physical 
examination and her clinical history. Therefore, it is also unclear why she requires a pressure reducing mattress. 
Therefore, the high strength lightweight manual wheelchair and pressure reducing mattress 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lightweight wheelchair and pressure-reducing mattress.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service April 7, 
2022. You asked the Plan to pay for procedure code 88341. You say that you are unable to locate any conflict in 
billing. The Plan denied your request. The Plan says payment for code 88341 is bundled into payment for code 
88360. 
 
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 88341 is a column II code to column I code 88360. The code at issue 
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 
88341 billed for date of service April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary, as a regular wheelchair 
will not help. The Plan denied your request. The Plan says a formal mobility assessment is needed in order to 
determine the appropriate mobility assistive item.  
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.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found that this request 
explicitly states that the scooter is for use outside of the home. This would only be authorized to accomplish 
MRADLs inside the home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment codes E0673 and E0675 billed 
for date of service October 13, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was for use during surgery. The 
Plan denied your request. The Plan says the devices are not separately payable. 
 
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 durable medical equipment was provided for use in an ambulatory surgical center. Although this item may 
be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided 
that the Plan does not have to pay for durable medical equipment codes E0673 and E0675 billed for date of 
service October 13, 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 requesting an expedited 
reconsideration stating the enrollee meets LTACH admission criteria. 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 11, 2022. 
 You asked the Plan to pay for the lab services. You say that the testing is a covered service. The Plan denied 
your request. The Plan says the medical records do not show why this test was required. 
 
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. In this case, there are insufficient medical records from the enrollees 
treating physician to show that the rules for coverage have been met. Therefore, we decided that the Plan does 
not have to pay for the lab testing services provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show the benefit from the prior injections. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the lack of documentation precludes a repeat epidural steroid injection at this time. There was 
previously an injection in September 2022, but there is no documentation as to the degree and duration of the 
pain relief from that injection Furthermore, there is documentation of six sessions of physical therapy focused 
on the hip, with no documentation of therapy directed at the back. 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drug, zoledronic acid. The records do not show that the required drug would be contraindicated 
or less effective; therefore, Prolia is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block provided on April 9, 2022. 
 
You asked the Plan to pay for the genicular nerve block. You say that the genicular nerve block was medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of a genicular nerve 
block in the setting of chronic pain and right knee osteoarthritis has not been demonstrated in the peer-reviewed 
literature. 
 
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 genicular nerve block. Our reviewer says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablations are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to 
knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are 
considered experimental/investigational in nature. The requested block is not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for a genicular nerve block provided on April 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine (72141). 
 
You asked the Plan to pre-approve an MRI of the cervical spine. The Plan denied your request. The Plan says 
this request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the cervical spine. Our 
reviewer says that an MRI of the cervical spine is not reasonable and necessary for the enrollee. Our physician 
reviewer found during an encounter of April 12, 2023, no red flags were noted. No weakness and no reflex 
abnormality. Our reviewer found that an electromyography (EMG) is planned but no results.  No plain x-rays 
have been done. Our physician reviewer found that absent the above info and absent a red flag there is no 
contraindication to a 6-week trial of PT prior to going forward with MRI. 
 
 
 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 MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on July 14, 2022, by an out-
of-network (OON) provider. 
 You asked the Plan to pay for the services provided by. The Plan denied your request. The Plan says the 
services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
We looked at the file and the rules. The Plan did not pre-approve the services at issue. There were no medical 
records provided to show that the services were urgent/emergent, or medically necessary. We found no 
exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not 
have to pay for the physician services provided on July 14, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 2 standard power wheelchair (K0823) and the 
requested items/accessories (E1028, K0108, E0973, E0978, E2365). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not medically necessary. 
 
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.  
 
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 DME. Our physician reviewer found a group 2 standard power wheelchair (K0823) is not medically necessary. You have a mobility deficit 
that impairs MRADL participation. Per Periscope the evaluation, you can safely walker with your walker in 
your apartment. The Periscope evaluation does not indicate that you can safely maneuver the requested power 
wheelchair in your apartment which would not allow the requested K0823. You can access your bedroom, 
bathroom, and kitchen with a four wheeled walker safely. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the group 2 standard power wheelchair (K0823) and the requested items/accessories (E1028, 
K0108, E0973, E0978, E2365).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pacemaker implantation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that pacemaker implantation is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has bradycardia on 
amiodarone. The amiodarone was stopped. As such, there is no evidence of irreversible, symptomatic 
bradycardia. The evidence provided would not meet criteria for pacemaker implantation. The services are not 
reasonable or medically necessary at this time. 
 
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 pacemaker implantation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, pemetrexed, carboplatin, and dexamethasone 
sodium phosphate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has right triple 
negative breast cancer that is BRCA2 positive. No driver mutations, specifically EGR and ALK, are provided 
and there are no PDL1 results in the submitted records. The records do not support that the requested drugs are 
reasonable and medically necessary at this time. 
 
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 Keytruda, pemetrexed, carboplatin, and dexamethasone sodium phosphate.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate (HDR) electronic brachytherapy (0394T 
x10). 
 
You asked the Plan to pre-approve HDR electronic brachytherapy. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been 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 HDR electronic brachytherapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are no compelling reasons offered for why stereotactic radiotherapy 
(SRT) would be needed over more standard approaches of radiation delivery or surgical approaches. The services are not medically necessary due to lack of demonstration of need for SRT vs. traditional external beam 
radiation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HDR electronic brachytherapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve high dose rate (HDR) electronic brachytherapy (0394T x10).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery 
(22869). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is in pain and this procedure would 
allow the enrollee to regain quality of life. The Plan denied your request. The Plan says the service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is experimental. More research is needed. 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250). 
 
You asked the Plan to pre-approve the dental service. You say that you are requesting an expedited 
reconsideration because the abscess is affecting your whole body. The Plan denied your request. The Plan says 
dental code D7250 is not listed as a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of residual tooth roots (D7250).