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

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 17, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service August 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a breast prosthesis. You say that the enrollee would benefit from a breast 
prosthesis, mastectomy sleeve to reduce the risk of left arm lymphedema. The Plan denied your request. The 
Plan says the requested item does not meet the definition of a prosthesis and is not covered by Medicare. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of a breast prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-
approve a breast prosthesis, mastectomy sleeve (L8010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral device/appliance used to reduce upper airway 
collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (E0486). You asked the Plan to pre-approve an oral device. You say that this appliance is to treat a medical condition 
called obstructive sleep apnea. The Plan denied your request. The Plan says the enrollee must have an in-person 
clinical evaluation by the treating practitioner prior to the sleep test. The enrollee was not assessed for sleep 
apnea and does not meet criteria for approval. 
 
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. The records show the enrollee had a sleep test in 2016. The records 
also show that the enrollee was not assessed by the treating practitioner on 8/2/2022 or 9/12/2022. The rules 
say that the device is ordered by the treating practitioner following a review of the report of the sleep test. No 
sleep test was recently made. The LCD confirms that if all criteria is not met, the oral appliance will be denied 
as not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of an 
oral device have not been met. Therefore, we decided that the Plan does not have to pre-approve an oral 
device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, 
includes fitting and adjustment (E0486).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting the Plan to reconsider an acute 
inpatient rehabilitation facility. The Plan denied your request. The Plan says your records show that it is not 
reasonable to expect that you will be able to safely participate in, or fully benefit from, the intensity of services 
of an IRF. Your rehabilitation needs are not complex, and you do not need to see a rehabilitation doctor 3 times 
a week. You can safely receive the services you need in other settings, for example, a skilled nursing facility, 
home with home health services or perhaps home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided safely in a different level of care. There is not 
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Juvederm. 
 
You asked the Plan to pre-approve Juvederm. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
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 Juvederm. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the requested drug is being prescribed to correct eyelid retraction due to traumatic scar tissue. 
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. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Juvederm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Juvederm.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiaxial ankle with swing phase active dorsiflexion 
feature and flex-walk system. 
 
You asked the Plan to pre-approve multiaxial ankle with swing phase active dorsiflexion feature and flex-walk 
system. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthesis accessories are only covered for certain 
indications. 
 
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 multiaxial ankle with swing phase 
active dorsiflexion feature and flex-walk system. Our reviewer says that the documentation does not support 
that the requested items are medically reasonable or necessary. Our physician reviewer found the 
documentation shows that the enrollee has historically ambulated unassisted with cane assistance on unlevel 
ground. Use of a cane is not consistent with a K3 level ambulator. Records also report the enrollee has the 
ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces which is the 
definition of a K2 ambulatory level. The documentation does not support that the enrollee is a K3 ambulator. 
There is no clear documentation that support that the enrollee is a K3 ambulator to meet Medicare criteria for 
the requested K3 accessories. Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multiaxial ankle with swing phase active dorsiflexion feature and flex-walk 
system have not been met. Therefore, we decided that the Plan does not have to pre-approve multiaxial ankle 
with swing phase active dorsiflexion feature and flex-walk system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trastuzumab-Anns (Kanjinti) (Q5117), Fluorouracil 
(J9190), Nivolumab (Opdivo) (J9299), Cisplatin (J9060), and Leucovorin (J0640). 
 
You asked the Plan to pre-approve the drug regimen. You say that if the enrollee does not receive this 
treatment, they may not live that long. The Plan denied your request. The Plan says the requested drug regimen 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the drug regimen. Our reviewer says 
that the requested drug regimen of trastuzumab-Anns, Fluorouracil, Nivolumab, Cisplatin, and Leucovorin is not medically necessary. Our physician reviewer found the requested use of trastuzumab-Anns, Fluorouracil, 
Nivolumab, Cisplatin, and Leucovorin is not approved by the Food and Drug Administration (FDA) for the 
enrollee's condition. The reviewer also found that the requested use is not supported by the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer 
found that the requested drug regimen is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug regimen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve trastuzumab-Anns (Kanjinti) (Q5117), Fluorouracil (J9190), Nivolumab (Opdivo) 
(J9299), Cisplatin (J9060), and Leucovorin (J0640).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you believe the denial of the Intracept 
procedure is unwarranted and unsupported by the enrollee's current medical status and current peer-reviewed 
literature. The Plan denied your request. The Plan says there are not enough studies to show the Intracept 
procedure improves the health of patients with the enrollee's medical condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (64555) and an implantable neurostimulator, pulse generator (L8679). 
 
You asked the Plan to pre-approve electrical stimulators. You say that the requested procedure is medically 
necessary. The enrollee would be an excellent candidate for the PENS to help with chronic pain and reduce the 
use of narcotics. The Plan denied your request. The Plan says the request does not meet the Medicare or health 
plan coverage criteria. 
 
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. The following devices are listed under the Food and Drug 
Administration (FDA) approval documents as electro-acupuncture devices used for stimulation of 
AURICULAR acupuncture points and as such are non-covered. Acupuncture for stimulation of AURICULAR 
points is not a covered Medicare benefit. Based on this information, we decided that Medicare rules for 
coverage of electrical stimulators have not been met. Therefore, we decided that the Plan does not have to pre-
approve a percutaneous implantation of neurostimulator electrode array; peripheral nerve (64555) and an 
implantable neurostimulator, pulse generator (L8679).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) surgery. 
 
You asked the Plan to pre-approve PVA surgery. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee's fracture is now more than 6 months old and the enrollee 
has a fracture retropulsion. 
 
The Plan follows Medicare rules. Medicare rules state that PVA surgery may be covered under certain clinical 
criteria. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PVA surgery. Our reviewer says that 
the enrollee does not meet criteria for PVA surgery. Our physician reviewer found the enrollee demonstrated 
moderate, anterior wedging compression deformity/fracture of L1 vertebral body, mild undulating contour the 
posterior cortex consistent with burst component, approximately 30% height loss anteriorly and mild vertebral 
body edema. Therefore, due to the burst component with plausible spinal instability, the enrollee has a 
contraindication for this request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (PVA) surgery.
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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH 
 
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 that all medically necessary care is being provided in the current acute care 
setting.  There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the Plan. The Plan has approved ongoing care in the current acute care 
setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back-up (E1399). 
 
You asked the Plan to pre-approve a battery back-up. You say that the enrollee has frequent power outages and 
cannot raise or lower the bed when the power goes out. The Plan denied your request. The Plan says this 
service is not covered by Medicare or the Plan. 
 
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 battery back-up (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro Motion G orthosis. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current clinical guidelines designate robotic therapy to be of "uncertain utility 
compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment. No reports from physical therapy or occupational therapy are provided which recommend the 
requested device 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 a MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve underpads. 
 
You asked the Plan to pre-approve underpads. You say that you have been receiving this benefit since 2019 and 
it is a medically necessary item. The Plan denied your request. The Plan says the requested items are not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve underpads.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve kidney transplant. 
 
You asked the Plan to pre-approve kidney transplant. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 kidney transplant. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found cardiac clearance determination for kidney transplantation is done by the Transplant Center. 
First The Center reviews the records to see if the enrollee is a candidate for workup for transplant, and then 
during the transplant workup they determine the level of cardiac clearance necessary. This ranges from none to 
referral to Cardiology. It is determined on a case-by-case basis by The Center. Therefore, the enrollee meets 
criteria for the requested 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 kidney transplant have been met. Therefore, we decided that the Plan has to pre-
approve kidney transplant.  
 
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.