Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural injection (TFESI) services at a 
second level bilaterally. 
 
You asked the Plan to pre-approve TFESI services at a second level bilaterally. You say that the TFESI 
services in dispute are medically necessary. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two transforaminal injections may 
be performed at a single setting. 
 
We looked at the file and Medicare rules. The records show that the enrollee has been approved for bilateral 
injections at a single level. Based on this information, we decided that Medicare rules for coverage of TFESI 
services at a second level bilaterally have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transforaminal epidural injection (TFESI) services at a second level bilaterally.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided 
December 1, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the physician did prescribe this 
device because they felt it was necessary for the medical safety of the enrollee. You feel you should be 
compensated for the services which was received. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery.  
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is 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 PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0676) provided December 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation used for sacro-iliac joint pain 
(64625) provided December 21, 2021. 
 
You asked the Plan to pay for radiofrequency ablation procedure. You say that the enrollee received the 
injection as pain management. Attached are the medical records. Please review for payment. The Plan denied 
your request. The Plan says the services do not meet coverage requirements. 
 
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. Radiofrequency ablation used for sacro-iliac joint pain is considered 
not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation procedure 
have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation 
used for sacro-iliac joint pain (64625) provided December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CPAP supplies to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network DME. You say that you have been receiving her CPAP 
supplies from the requested provider for over two years and prior to joining the health plan. The Plan denied 
your request. The Plan says the services are not emergent or urgent and are available within the network. 
 
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 
the CPAP supplies to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diabetic supplies. 
 
You asked the Plan to pre-approve the diabetic supplies. You say that the diabetic supplies are necessary. The 
Plan denied your request. The Plan says you did not provide any additional information to verify medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 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 diabetic supplies have 
been met. Medical records were not provided to verify the diabetic supplies is necessary. Therefore, we decided 
that the Plan does not have to pre-approve the diabetic supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laparoscopy (CPT code 43644) and inpatient 
hospital care. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked 
at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. The enrollees BMI is stated to be at 32 and according to the NCD it must be at 
least 35. Therefore, we decided that the Plan does not have to pre-approve the laparoscopy (CPT code 43644) 
and inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer assisted surgical navigation MAKOplasty 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 the clinical value and effectiveness of MAKOplasty for robotic 
assistance in the setting of a left hip arthroplasty 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 pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology (with regards to ultimate improved outcomes of pain reduction and 
functionality improvement). There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 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 computer assisted surgical navigation MAKOplasty for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for doppler echocardiography (93321, 93325) provided on 
November 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for doppler echocardiography. You say that these services were pre-approved and 
medically necessary. The Plan denied your request. The Plan says the prior authorization on file is only for 
93350. The requested services were not pre-approved. The provider in this case is a non-contracted provider 
and did not obtain the necessary authorization for these codes/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 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for doppler echocardiography (93321, 93325) 
provided on November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional chiropractic care. 
 
You asked the Plan to pre-approve additional chiropractic care. The Plan denied your request. The Plan says 
there is no further clinical benefit that can be expected from ongoing chiropractic 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 additional chiropractic care. Our 
reviewer says that the requested additional chiropractic care is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the limited documentation is insufficient to support that 
chiropractic care is medically reasonable and necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional chiropractic care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional chiropractic care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the recliner chair. 
 
You asked the Plan to pre-approve the recliner chair. You say that your medical condition can only be 
improved by keeping your legs above your head and the lift chair is the only options for this treatment method 
without causing pain or possible treatment complications. The Plan denied your request. The Plan says a 
recliner chair is not for a medical problem. 
 
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 the recliner chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 19, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says an 
authorization was not obtained prior to the services being rendered and the provider is not participating with the 
member's Plan. 
 
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 
physicians services. 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 physician's services provided on January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis for the enrollee. 
 
You asked the Plan to pre-approve Lucentis. You say that this is medically necessary. 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 Lucentis. Our reviewer says that 
Lucentis is not medically reasonable and necessary. There is no indication that the patient has tried and failed 
bevacizumab (Avastin). There is no indication that the Plan's required drug would likely be less effective 
and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition 
does not meet step therapy criteria for Lucentis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor (CPT code E0667) and pneumatic compressor, segmental home model with calibrated gradient 
pressure (CPT code E0652). 
 
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 enrollee's request is not medically necessary because the enrollee's records show 
they do not have truncal or chest swelling due to lymphedema. 
 
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 exam and records did not document any swelling of the abdomen or trunk due to lymphedema. The 
provider states the enrollee had problems using an E0651 pump due to pain in the legs. The records do not 
show that the enrollee has consistently or recently tried compression, exercise, and elevation to help the edema. 
The review has determined that the medical records provided do not meet the requirements listed in the 
LCD/NCD for Medicare coverage. 
 
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 segmental pneumatic appliance for use with pneumatic compressor (CPT code E0667) and 
pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the right knee brace (L1833) with suspension sleeve (L2397) 
and condylar pad (L2810) provided on December 8, 2021. 
 
You asked the Plan to pay for the right knee brace. You say that this was a medically necessary brace and 
should be covered. The Plan denied your request. The Plan says the ordering provider signed a pre-filled form 
from the equipment supplier. This means that the order is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that knee braces are covered for the conditions listed 
in the Medicare rules section of this decision. 
 
The progress notes submitted do not indicate any injury or surgical procedure to the knee. There is also no 
documentation of knee instability. The notes do not include a complete objective physical examination of the 
knee. Based on the information available, we find that the criteria for the coverage of this knee brace have not 
been met. Therefore, we decided that the Plan does not have to pay for the right knee brace (L1833) with 
suspension sleeve (L2397) and condylar pad (L2810) provided on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wig to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the wig. You say that your hair is falling out due to metastatic breast cancer 
treatment. The Plan denied your request. The Plan says the wig is not reasonable and necessary for treatment of 
illness or injury, and it is not used to serve a medical purpose. The Plan states out-of-network services are not 
covered.  
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. Furthermore, 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 
the wig to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketamine. 
 
You asked the Plan to pre-approve Ketamine. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Ketamine. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Ketamine is medically reasonable and necessary for the enrollee. The 
documentation does not support that the Ketamine is safe and effective 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 Ketamine have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ketamine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from May 3, 2021, to 
May 7, 2021, with diagnosis related group (DRG) 896. 
 You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of secondary diagnosis code G92 with DRG 896. The Plan denied your request. The Plan says the 
medical records do not support the billing of secondary diagnosis code G92 with DRG 896. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with G92. 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 inpatient hospital services. Our reviewer says that the medical records do not support the 
billing of secondary diagnosis code G92 with DRG 896. Our physician reviewer found the documentation 
indicates that the enrollee presented to the facility with a chief complaint of acute alcohol intoxication and 
requested referral to inpatient rehab for assistance with alcohol cessation. The enrollee's alcohol level on 
admission was 359. The enrollee's past medical history included obesity, chronic obstructive pulmonary disease 
(COPD), congestive heart failure, alcohol abuse, tobacco abuse, hypertension, and atrial fibrillation. The 
enrollee was initially placed on Ativan as needed for withdrawal symptoms. On May 4, 2021, the progress 
notes indicated that the enrollee had visual and tactile hallucinations and was started on oral Librium. With 
treatment, the enrollee's symptoms improved, and the discharge summary indicated a diagnosis of "Acute toxic 
encephalopathy due to alcohol intoxication." The review has determined that the medical records did not 
support the billing of secondary diagnosis code G92 with DRG 896.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from May 3, 2021, to May 7, 2021, with diagnosis related group 
(DRG) 896.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the bed is necessary. The Plan 
denied your request. The Plan says the bed is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the total electric hospital bed have not been met. The rules say that 
a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is 
a convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we 
decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265).