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

 
We decided that the Plan does not have to pre-approve power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the clinical information did not contain documentation of a mobility limitation which 
impairs the ability to complete activities of daily living in the home and that limitation can only be resolved 
with a scooter, that the requested device is appropriate for the enrollees weight, or that the home provides 
adequate access for use of the requested device. The Plan states the available documentation supports that this 
power mobility device is needed for recovery after planned ankle surgery which supports that the condition is 
reversible, and the need is less than three (3) months. 
 
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 the clinical documentation does not show that the enrollee would not be able to use a manual wheelchair or that the enrollee would be able to safely operate a group 1 power mobility device inside the enrollee's home; 
thus, this 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power operated vehicle, group 1 standard, patient weight capacity up to and including 300 
pounds (CPT code K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade for the enrollee. 
 
You asked the Plan to pre-approve Remicade. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the 
preferred products. 
 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 Remicade. Our reviewer says that 
Remicade is not medically reasonable and necessary. The Plan requires a trial of Humira before they will 
approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no 
documentation provided indicating that the Plan's required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet 
step therapy criteria for Remicade. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64635, 64636). 
 
You asked the Plan to pre-approve the injections. You say that you had some relief on the right side with the 
last injection, but it didn't provide the relief you normally get from the injection received on the left side. The 
Plan denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and 
necessary for patients who meet all the criteria.  
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 injections. Our reviewer says that 
the injections are not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has had a minimum of consistent 50% improvement in pain for at least six (6) months 
or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as 
compared to baseline measurement using the same scale from the previous thermal facet joint RFA at the same 
anatomic site. Therefore, the reviewer found that the requested injection 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64635, 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Opioid Treatment Programs provided from January 4, 2021, 
to October 4, 2021. 
 
You asked the Plan to pay for Opioid Treatment Programs. You say that these services are deemed medically 
necessary by the provider as they are the only Opioid treatment facility within a 20-mile radius for the member 
and are the only facility which can provide this treatment. The Plan denied your request. The Plan says the 
member's primary care provider did not refer for services. The health Plan requires utilization of network 
providers when possible and available and requires authorization for certain services. No medical necessity for 
an out-of-network provider, such as an urgent or emergency situation, has been documented. There is no 
network deficiency for these services and alternate network providers were found. 
 
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. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. 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 Opioid Treatment Programs provided from January 4, 2021, to 
October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation care. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01470) provided on January 29, 
2021. 
 
You asked the Plan to pay for code 01470. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the anesthesia services (01470) provided on January 29, 2021, have been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services (01470) provided on January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the device is medically necessary. 
The Plan denied your request. The Plan says although the requested device is reported as having some utility in 
post-stroke rehabilitation in terms of facilitating recovery, it is not considered the standard of care. 
 
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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the clinical documentation does not support that the requested orthotic device is an 
accepted standard of medical practice that meets but does not exceed the enrollee's medical need. It does not 
indicate that the device is at least as beneficial as existing and available medically appropriate alternatives. 
There is insufficient medical literature with controlled studies demonstrating the efficacy of this device. 
Controlled trials do not support that daily function is improved with the use of the device. Studies to date are of 
small size and take place in controlled environments. Additional studies are necessary to establish efficacy. The 
evidence is insufficient to determine the effects of this technology on long-term health outcomes. 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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (E&M) services under code 
99205, provided on March 3, 2022. 
 
You asked the Plan to pay for code 99205. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a new patient is a patient who has not received 
any professional services from the physician or physician group practice within the previous 3 years. In this case, the enrollee was seen by another provider within the same physician group practice on March 2, 
2022. This is not a new patient per Medicare rules. Therefore, we decided that the Plan does not have to pay for 
the evaluation and management (E&M) services under code 99205, provided on March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the multiple density inserts provided on November 9, 2021. 
 
You asked the Plan to pay for the multiple density inserts. You say that you verified benefits and were quoted 
80% coverage for 3 pairs per year. You say that the claim should be reprocessed for payment as it is a covered 
benefit. The Plan denied your request. The Plan says procedure code A5513 was not billed with the appropriate 
KX modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code A5513 is for diabetics only, multiple density insert, 
custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer 
minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping 
material, custom fabricated, each.  We find that CPT code A5513 is not supported in the medical record. Specifically, the appropriate modifier 
was not billed with CPT code A5513. Based on this information, we decided that Medicare rules for coverage 
of the multiple density inserts have not been met. Therefore, we decided that the Plan does not have to pay for 
the multiple density inserts provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that completed studies say that this procedure does not improve 
outcomes compared to standard treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. These services have 
not been proven effective and are considered experimental/investigational. Our physician reviewer found that 
the enrollee's condition does not meet criteria for coverage of these services. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation of the sacroiliac joint for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an iron study (83540) provided on March 31, 2022. 
 
You asked the Plan to pay for an iron study. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the diagnosis is inconsistent with the study. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a list of diagnosis codes for which iron 
studies are covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of iron study have not been met. Specifically, none of the billed diagnosis codes appear on the 
covered list. As such, this denial is supported. Therefore, we decided that the Plan does not have to pay for an 
iron study (83540) provided on March 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to extend the SNF care. 
 
You asked the Plan to extend the SNF care. You say that the SNF care is medically necessary to continue your 
treatment. The Plan denied your request. The Plan says the enrollee no longer requires inpatient skilled 
therapies or services. Further care, based on enrollee's current functional level or medical service level, can be 
provided in an alternate setting of care. 
 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 extend the 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 there are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services daily basis. This 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to extend the SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64491, 64490). 
 
You asked the Plan to pre-approve the injections. You say that the injections are needed. The Plan denied your 
request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all of the criteria. 
 
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 injections. Our reviewer says that 
the requested facet joint injections are not medically necessary. Our physician reviewer found the provided documentation does not include advanced imaging to show that there is no non-facet pathology present as 
required by the guidelines. Therefore, the reviewer found that the requested injections 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64491, 64490).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records 
provided. 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 provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on February 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the date of service billed 
(February 15, 2022) does not match the date the specimen was collected (September 10, 2018). Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81479) provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 the home ventilator. Our physician 
reviewer found Medicare does not cover a home ventilator when used as bilevel positive airway pressure 
(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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a duplex ultrasound scan of the neck. 
 
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 that the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a duplex arterial scan 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 medically necessary. Our physician reviewer found the enrollee had an episode of chest pain 
and passing out. Her history and physical examination are suspicious for transient ischemic attack. Part of the 
standard workup in such a case is a duplex ultrasound exam of the carotid and vertebral arteries. The services 
are therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve a duplex ultrasound scan of the neck.  
 
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.