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

 
We decided that the Plan does not have to pre-approve a right sciatic nerve injection (64445). 
 
You asked the Plan to pre-approve a right sciatic nerve injection. You say that you would like this procedure to 
be reconsidered for coverage. The Plan denied your request. The Plan says the medical necessity criteria was 
not met because there is not enough medical evidence that shows this type of nerve block (Sciatic Nerve Block) 
is helpful for the pain the enrollee has. 
 
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 right sciatic nerve injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures. Additionally, the recent exam did not 
corroborate radicular pain. Our reviewer found that there are limited large-scale, long-term references showing 
the safety and efficacy of the requested injection in this clinical setting. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Our physician reviewer also found that the documentation does not support that the right sciatic nerve injection, 
in this case, is medically reasonable and necessary and does not support that the sciatic nerve injection 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 a right sciatic nerve injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a right sciatic nerve injection (64445).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ruxience (Rituximab). 
 
You asked the Plan to pre-approve Rituximab. The Plan denied your request. The Plan says currently, there is 
no indication for the use of Rituximab in monoclonal gammopathy of undetermined significance. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Rituximab. Our reviewer says that 
Rituximab is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of monoclonal gammopathy of undetermined significance. The FDA 
has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and 
the requested service cannot be recommended. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ruxience (Rituximab).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy 
(NPWT) pump. 
 
You asked the Plan to pre-approve NPWT pump. You say that the enrollee would benefit from use of the 
wound vacuum. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that continued use of a negative pressure wound therapy 
(NPWT) pump may be covered if certain 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 NPWT pump. Our reviewer says that 
the enrollee does not meet criteria for continued use of the NPWT pump. Our physician reviewer found the 
records submitted do not contain sufficient documentation of a licensed medical professional supervising or 
directly performing NPWT dressing changes and documenting changes in the ulcer's dimensions and 
characteristics on a monthly basis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NPWT pump have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a negative pressure wound therapy (NPWT) pump.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee (L5856). 
 
You asked the Plan to pre-approve a microprocessor knee. You say that this item is medically necessary. The 
Plan denied your request. The Plan says that this item is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 microprocessor knee. Our reviewer 
says that this item is medically necessary. Our physician reviewer found the patients current prosthesis 
requires replacement and is not functioning properly and fitting properly due to anatomical changes. The 
patient requires a prosthesis for mobility and performing daily activities. She is noted to be able to walk on 
uneven surfaces and is a community ambulator. The patient was tested using the amputee mobility predictor 
and was noted to be a K3 level ambulator. She has full motor strength and range of motion in the lower 
extremities except for below her amputation and does not have significant cardiac or respiratory issues that 
should prevent her from being a K3 level ambulator. She is currently unstable with her existing hydraulic knee 
joint and using a cane for assistance with mobility. A microprocessor knee joint will add increased control and 
enhance stability. 
 
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 microprocessor knee have been met. Therefore, we decided that the Plan has 
to pre-approve a microprocessor knee (L5856).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve radiation therapy with an out-of-network provider. You say that you want to 
see this provider because it is closer. The Plan denied your request. The Plan says out-of-network services are 
not approved unless they are not available in-network or are emergent. 
 
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 
radiation therapy 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 pay for procedure codes 99100 and 99140 billed for date of service 
September 19, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says procedure codes 99100 and 99140 are considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
September 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system and power seat elevation 
system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is able to control power options using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that a power seat elevation system was requested. We looked at the file and the rules. A power 
seat elevation feature (E2300) is non-covered because it is not primarily medical in nature. Based on this 
information, we decided that the Medicare rules for coverage have not been met. 
 
The file shows that an expandable control system was requested. 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 requested services. Our physician reviewer found that the provided records 
document that the enrollee has strength to hold against partial resistance and is independent with feeding, 
grooming and dressing, thus indicating she has adequate upper extremity strength and function to operate the 
wheelchair's power options with their own switches. Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable control system and power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) visits (97110, 97112, 97116, 
97161) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT visits. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you must use network providers to get your medical care and services. There are in-
network providers available with your 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 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 
physical therapy (PT) visits (97110, 97112, 97116, 97161) to be provided by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are very confused and need more time in SNF 
and therapy services. The Plan denied your request. The Plan says you no longer require daily skilled therapy. 
 
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 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 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87150 provided on May 18, 2022. 
 
You asked the Plan to pay for procedure code 87150. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that procedure code 87150 is not supported. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure code 87150 by a contract provider. The file does not show that the plan 
provided notice that procedure code 87150 would not be covered. Under Medicare rules, this means procedure 
code 87150 is considered approved by the plan. Therefore, we decided that the Plan has to pay for procedure 
code 87150 provided on May 18, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopedic footwear, mens shoe, Oxford, each (L3219). 
 
You asked the Plan to pay for foot orthotics. You say that when the documentation was requested it all was sent 
over. You are attaching the same file as you did before. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the orthopedic footwear, mens shoe, 
Oxford, each (L3219).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost-sharing amount applied to a crown - porcelain fused 
to predominantly base metal represented by code D2751 provided on November 8, 2022. You asked the Plan to adjust the cost-sharing amount applied to code D2751. You say that the dentist quoted 
you a different amount for your liability. The Plan denied your request. The Plan says the cost sharing was 
appropriately applied to the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for Class 3 Major Services. You contract with the Plan also clearly says that you must pay the 
difference between a less expensive alternate procedure and a more expensive procedure billed by an out-of-
network provider. 
 
You have been asked to pay a 50% coinsurance for code D2751. This percentage is based on the allowed 
amount of $767.32, totaling a $383.66 coinsurance (50% x $767.32 = $383.66). This item/service falls within 
the Class 3 Major Services benefit category. You have also been asked to pay the difference between the 
allowed amount of the more expensive procedure billed by the out-of-network provider (D2750) which was 
$823.46 and the allowed amount of the less expensive alternate procedure that the Plan paid (D2751) which 
was $767.32.  This difference totaled $56.14. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to adjust the cost-sharing amount 
applied to a crown - porcelain fused to predominantly base metal represented by code D2751 provided on 
November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring system. 
 
You asked the Plan to pre-approve this item. You say that this item is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the requested item. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 this item. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested item. Our physician reviewer found that the 
records do not document that the enrollee is insulin treated with three or more daily administrations of insulin 
or a Medicare-covered continuous subcutaneous insulin infusion pump.  Additionally, the records do not document that the enrollee's insulin treatment regimen requires frequent 
adjustment from the beneficiary on the basis of blood glucose monitoring or continuous glucose monitor testing 
results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in 
the home health setting (G0151 x 6) and the direct skilled nursing services of a registered nurse in the home 
health setting (G0299 x 6) to be rendered by the out-of-network (OON) provider at an in-network benefit level. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to perform 
the requested services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that as a member of the Plan, you can choose to receive care from out-of-network providers. 
However, if you use an out-of-network provider, your share of the costs for covered services may be higher.  
 
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 at an in-network benefit level.  You may choose to receive services from this provider at the out-of-network benefit level, but your share of 
costs for covered services may be higher. Therefore, we decided that the Plan does not have to pre-approve 
services performed by a qualified physical therapist in the home health setting (G0151 x 6) and the direct 
skilled nursing services of a registered nurse in the home health setting (G0299 x 6) to be rendered by the  
out-of-network (OON) provider at an in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested item is a necessity 
for your care. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 a total electric hospital 
bed (E0265).