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

 
We decided that the Plan does not have to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are subject to the criteria 
listed 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 facet joint injection services. Our 
reviewer says that the requested injection services are not medically reasonable and necessary. Our physician 
reviewer found that the enrollee is a 67-year-old female with a history of low back pain/right gluteal area pain/right sacroiliac joint pain. The pain is rated 5/10 and is exacerbated by activity but is present all of the 
time.  
 
In this case, there is no documentation provided indicating that the facet joint is the source of the enrollee's 
pain.  The review has determined that the enrollee does not satisfy the LCD criteria.  The requested injection 
services are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that the enrollee would benefit from the 
use of compression stockings to address chronic venous insufficiency, which is causing her bilateral leg pain. 
The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital services (99232) provided on 
October 18, 2021. 
 
You asked the Plan to pay for the subsequent hospital services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this exceeds the contracted 
maximum number of hours/days/units by this provider for this period. 
 
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 99232 is not supported in the record. Specifically, the documentation shows that the 
Plan processed and paid CPT code 99232 for the same date of service and same provider. CPT code 99232 may 
only be billed once by the same provider on the same date of service. Based on this information, we decided 
that Medicare rules for coverage of the subsequent hospital services have not been met. Therefore, we decided 
that the Plan does not have to pay for the subsequent hospital services (99232) provided on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight manual wheelchair. 
 
You asked the Plan to pre-approve an ultralightweight manual wheelchair. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item 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 an ultralightweight manual wheelchair. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
insufficient documentation from the patient's medical provider that specifies that this patient has a personal 
mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, 
grooming and bathing in customary locations within 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 an ultralightweight manual wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultralightweight manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed. 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that you feel this bed is extremely 
medically necessary and so does the doctor. The Plan denied your request. The Plan says this item is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the enrollee needs a ramp for safety issues. 
The Plan denied your request. The Plan says it is not primarily used to serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total knee arthroplasty. 
 
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 a knee arthroplasty 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 you are being treated for unilateral 
primary osteoarthritis of the right knee. Exam of the right knee reveals tenderness and cracking (crepitation). 
There is no documentation of advanced osteoarthritis of the right knee confirmed by imaging studies. There is 
no trial and failure of recent, reasonable, and comprehensive conservative care measures, including 
viscosupplementation injections prior to surgery. The right knee arthroplasty 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 a right total knee arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve office visits and treatment to be provided by an OON provider. You say that 
you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network 
cardiologists available to you that can provide the care and treatment you are requesting. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says you must use a 
network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve services to 
be provided by an out-of-network (OON) provider.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be responding to current treatment and should only require 
short-term additional acute care services that can safely be administered at the current facility until more stable 
and appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to a lower level of care may be considered 
when treatment has completed. 
 
 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: 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 this is medically necessary. The Plan 
denied your request. The Plan says this 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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a 
chronic infected ankle wound with ostemyelitis. The enrollee is not intubated or ventilated. There is no 
evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed 
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee 
can remain at the current ACH until such time no acute services are required.  The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 June 3, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Part B coverage of the requested drug is subject to the 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial 
of Infed and Venofer before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drugs. 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monoferric for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemodenervation of muscle and onabotulinumtoxina 
injection for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no specific findings to approve this service. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of ventral hernia. The requested drug is being used for 
chemodenervation of muscle in preparation for surgery. The Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The noted 
indication is not a covered enumerated use of the requested service. The elements of the coverage criteria are 
not satisfied. 
 
 
 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chemodenervation of muscle and onabotulinumtoxina injection for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve MRI services. You say that it is necessary for you to receive these services 
from an OON provider. The Plan denied your request. The Plan says there are in-network providers that are 
available to provide the requested services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance imaging (MRI) services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucynta tablet 75mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug 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 Nucynta tablet 75mg.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Infed and Venofer before they will approve the requested drug. The requested drug is a 
new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-
one alternatives. The record does not indicate that the enrollee has a contraindication to, or would have an 
adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme (Q0138).