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

 
We decided that the Plan has to pre-approve the repairs and replacements on a power wheelchair. 
 
You asked the Plan to pre-approve the repairs and replacements on a power wheelchair. You say that the items 
should be covered. The Plan denied your request. The Plan says that a prescription for repair work with 
justification of each line item needs to be submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that to repair means to fix or mend and to put the 
equipment back in good condition after damage or wear. Repairs to equipment which a beneficiary owns are 
covered when necessary to make the equipment serviceable. If the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. A new Certificate of Medical Necessity (CMN) and/or 
physician's order is not needed for repairs. 
 
We looked at the file and the Medicare rules. The denial rationale from the Plan indicates that there is no 
prescription or justification for each line item being requested. However, as noted in the Medicare rule, an 
order or Certificate of Medical Necessity is not required for repairs of enrollee-owned equipment. The appeal 
document also provides detailed information about the broken components and the need to replace/repair them. 
We find that there is no lack of justification that these repairs are needed to make the equipment serviceable. 
The Plan also has indicated that more information is needed to determine whether replacement would be more 
appropriate. However, Medicare rules only prohibit repair costs which exceed the cost of replacement. Given 
that the estimate for repairs is shown to be less than replacement, if the enrollee elects to proceed with repairs 
rather than replacement, there is no provision which would require the latter. Based on the information 
available, we find that the denial of coverage for requested repairs is not substantiated. Therefore, we decided 
that the Plan has to pre-approve the repairs and replacements on a power wheelchair.  
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm Solution 170MG/1.7ML (CPT code J0172 
x6). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Aduhelm does not appear to be medically necessary. The Plan states magnetic 
resonance imaging (MRI) suggests a mixed pattern of abnormalities with microangiopathic changes and CSF 
analysis is incomplete as there is no documentation of the P-tau protein. The Plan states the submission 
included no validated objective rating scale showing mild cognitive impairment or mild dementia. 
 
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 medication. Our physician reviewer 
found the review has determined that the documentation does not support that the Aduhelm Solution 
170MG/1.7ML (CPT code J0172 x6) is medically reasonable and necessary for the patient. The documentation 
does not support that the Aduhelm Solution 170MG/1.7ML is safe and effective for the patient. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aduhelm Solution 170MG/1.7ML (CPT code J0172 x6).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on October 18, 2021. 
 You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says the code 
remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -XU modifier if 
the service billed with the modifier indicates a distinct procedural service.   
 
The file shows that lymphatic imaging was provided during a radiopharmaceutical localization procedure. The 
medical records provided do not show that the service billed with the -XU modifier was a distinct procedural 
service. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the imaging services provided on October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invokana 300MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Invokana is a self-administered drug is not covered under the enrollee's 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 Invokana 300MG tablet.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance mileage provided on October 27, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was transferred, needing a higher 
level of care. The Plan denied your request. The Plan says the Medicare rule for payment has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid.  
 
 
 We looked at the file and the rules. In this case, the MUE for CPT code A0425 is 250. You billed 314 units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance mileage provided on October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 15, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code cannot be verified. 
 
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. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 pay for the drug testing services provided on July 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided June 3, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you did not need a transport to the 
hospital. The Plan denied your request. The Plan says ambulance services are not covered when there is no 
transport.  
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 3, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT 
code 70450) provided on November 23, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 
70450) provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of a continuous positive airway 
pressure (CPAP) machine. 
 
You asked the Plan to pre-approve continued use of a CPAP machine. You say that you believe that this device 
should continue to be covered because it is medically necessary. The Plan denied your request. The Plan says 
the criteria for the continued use of a CPAP machine have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that adherence to positive airway pressure (PAP) 
therapy is defined as use of PAP =4 hours per night on 70% of nights during a consecutive thirty (30) day 
period anytime during the first three (3) months of initial usage. If the criteria have not been met, continued 
coverage of a PAP device and related accessories will be denied as not reasonable and necessary 
 
We looked at the file and Medicare rules. In this case, the record demonstrates that you have not used your 
machine at least 4 hours per night on at least 70% of nights during a consecutive thirty day period. Based on 
this information, we decided that Medicare rules for coverage of continued use of a CPAP machine have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the continued use of a continuous 
positive airway pressure (CPAP) machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
related supplies. 
 
You asked the Plan to pre-approve a therapeutic CGM and related supplies. You say that a therapeutic CGM 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 must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a therapeutic continuous glucose monitor (CGM) and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sit to stand lift. 
 
You asked the Plan to pre-approve the sit to stand lift. You say that the sit to stand lift is needed to help move 
the member. The Plan denied your request. The Plan says durable medical equipment (DME) is defined as an 
item that is primarily for use in the home AND is intended for repeated use, primarily used for a medical 
purpose, generally not useful to someone who is not ill or injured and is appropriate for use in the home. The 
Plan states the item requested does not meet these requirements and therefore, is not considered a covered 
DME item. 
 
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 sit to stand lift.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
September 26, 2021. 
 
You asked the Plan to pay for code 70450. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
September 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira 40mg/0.8 kit. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Humira 40mg/0.8 kit to be administered at home is not Medicare covered under the 
Part A or B benefit. 
 
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 Humira 40mg/0.8 kit.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc 850 25 MG/2.5ML (CPT code J7320). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says step therapy and medical necessity has 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 the medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the plans required drug(s) 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve GenVisc 850 25 MG/2.5ML (CPT code J7320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the general use wheelchair back cushion (CPT code 
E2611). 
 
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 DME is not covered. 
 
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 durable medical equipment (DME) have not been met. Review 
of the information does not show that the enrollee has a regular or power wheelchair with which to use the 
requested equipment. The rules say that if the beneficiary does not have a covered wheelchair, then the cushion 
will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-
approve the general use wheelchair back cushion (CPT code E2611).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on December 
9, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 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, the CPT Code Manual definition of code 70450 is computed tomography, head or brain; without 
contrast material. We find that CPT code 70450 may be eligible for payment when billed with code 70496. The 
claim does not show that the code at issue was billed with a modifier suitable for payment. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the computed tomography (CT) scan provided on December 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 21, 2021 to March 19, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the RAP claim was not submitted timely. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, Specifically, 
the record indicates that the RAP was not submitted within 5 days of the start of care date. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from February 
21, 2021 to March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Botox 200-unit solution (CPT code J0585). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not 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 medication. Our physician reviewer 
found the reviewed documentation indicates that the member has overactive bladder. The member has 
previously tried oxybutynin and was intolerant to it (confusion and dry mouth. The dose is 150 units as needed. 
The review indicates that the members dose of 150 units as needed exceeds the Food and Drug Administration 
(FDA) recommended dose of 100 units every 12 weeks. The review has determined that the medical records 
provided do not meet the requirements listed in the LCD 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Botox 200-unit solution (CPT code J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced care planning billed for services provided on 
June 2, 2021. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was in need of care. The Plan 
denied your request. The Plan says the service cannot be verified. 
 
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, the CPT Code Manual definition of code 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, the records provided do not 
include advanced care planning with the enrollee and surrogate. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the advanced care planning billed for services provided on June 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from 
March 18, 2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are still having problem with 
breathing and need more time to get better. The Plan denied your request. The Plan says the continued SNF 
level of care is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found that from March 18, 2022, forward 
you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or 
skilled therapy on an inpatient basis in a skilled nursing facility (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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care from March 18, 2022, forward.