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

 
We decided that the Plan does not have to pay for the limited ultrasound of the abdomen (76705) provided on 
November 23, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705.  
 This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an 
appropriate modifier was not billed with this PTP code edit. This service was not billed as required by 
Medicare coding regulations. 
 
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 the limited ultrasound of the abdomen (76705) provided on 
November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that you feel that your benefits should cover 
replacing your upper denture. You say that not having a denture is having an adverse effect on your ability to 
eat. You also say that it is affecting your health and wellness. The Plan denied your request. The Plan says an 
upper denture is covered once every 5 plan years. The Plan also says that the frequency limit has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage and 1 complete upper denture is 
covered per plan year, the frequency limit has been reached. The record shows that the Plan paid for a complete 
upper denture that you received on June 4, 2019. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can remain in the current acute care location until such time no 
further acute level care is needed. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is still somewhat unstable and should only 
require short-term additional acute care services that can be safely administered at the current facility until 
more stable. The enrollee does not require services at the LTACH that are not already available at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous to 
completing care at the current facility until appropriate for a lower level of care and more stable. 
  
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 permanent cardiac contractility modulation system 
(CCM). 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare 
due to insufficient evidence of efficacy. 
 
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. This device is being 
requested for the treatment of congestive heart failure (CHF) which has been deemed refractory to optimal 
medical therapy. An exhaustive review of the current medical literature pertaining to the CCM system confirms 
multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of 
CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, 
with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity.  
 While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. 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 a permanent cardiac contractility modulation system (CCM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and related accessories. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that the enrollee is unable to ambulate to 
accomplish activities of daily living. The Plan denied your request. The Plan says the enrollee does not have 
medical conditions to qualify for features in this wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair is only covered under 
certain medical indications.  
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair and related accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator 
electrodes. 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrodes. 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 follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
conditions 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 percutaneous implantation of 
neurostimulator electrodes. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found there is no documentation of a psychiatric evaluation. Criteria is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrodes have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator 
electrodes.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketamine infusions. 
 
You asked the Plan to pre-approve Ketamine. You say that this is the best and only treatment available to you. 
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the 
records do not show why this infusion needs to be repeated on a monthly basis. 
 
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 Ketamine. Our reviewer says that you 
do not meet the Medicare criteria for the requested use of Ketamine. Our physician reviewer found the Food & 
Drug Administration (FDA) has not stated that Ketamine is indicated for your condition. The requested use is 
not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved 
medical journal. 
 
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 infusions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), and a partial 
mandibular denture (D5214) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a complete maxillary denture and a partial mandibular denture. You say that 
you would like the Plan to pay for this. The Plan denied your request. The Plan says the requested dental 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), and a partial mandibular denture (D5214) to be provided by a 
participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that based on Medicare guidelines, the IRF services you and/or your provider are  
requesting do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollees medical problems are 
stable. There are no complex nursing or rehabilitation needs. 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 has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrocentesis (D7870). 
 
You asked the Plan to pre-approve the dental service. You say that you are not able to open your mouth enough 
to eat properly. You also say that you are not able to pay for this procedure out of pocket as you are not 
working and are on a limited income. The Plan denied your request. The Plan says arthrocentesis is not listed as 
a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested arthrocentesis is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
arthrocentesis (D7870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that a Flexitouch has been 
deemed medically necessary and appropriate by the health care team as the next treatment option. The Plan 
denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema 
pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services (97110) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON physical therapy. You say that it is easier for you to get to the out-of-
network provider without having to ask for help from family. The Plan denied your request. The Plan says 
there are in-network providers within a reasonable distance who are able to provide these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services (97110) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Repatha (evolocumab)for self-injection. 
 
You asked the Plan to pre-approve the Repatha. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a self-administered drug which Medicare Part B does not cover. 
 
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 the Repatha 
(evolocumab)for self-injection.  
 
Benefits for the Repatha 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is necessary. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid. 
 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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the required drug, zoledronic acid. There is no documentation provided 
indicating that the plans required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Specifically, the file does not show that the enrollee 
has tried and failed the plan's preferred drug. Therefore, we decided that the Plan does not have to pre-approve 
Prolia (J0897).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for SNF admission. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the member does not have any 
parental medication; complex wound care or nutrition given via a feeding tube.  He is medically stable without 
any acute exacerbations of chronic medical problems.  His physical function is at or near his baseline and he 
can receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehab services 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sinus perforation closure (D7261), and osseous tissue 
regeneration (D4265) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a sinus perforation closure and osseous tissue regeneration. You say that 
this has caused extreme pain and you have difficulty eating. You say that this is starting to damage your eyes. 
The Plan denied your request. The Plan says the requested dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a sinus perforation closure (D7261), and osseous tissue regeneration (D4265) to be provided by a participating 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET). 
 
You asked the Plan to pre-approve the PET. You say that you would like reconsideration because the requested 
service is medically necessary. The Plan denied your request. The Plan says Medicare does not cover PET 
scans for initial anti-tumor treatment strategy in beneficiaries who have adenocarcinoma of the prostate. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS continues to nationally non-cover initial 
anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate. Therefore, 
we decided that the Plan does not have to pre-approve  positron emission tomography (PET).. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET have not been met. Specifically, the records indicate that this service is being requested 
for initial anti-tumor treatment strategy for adenocarcinoma of the prostate. Therefore, we decided that the Plan 
does not have to pre-approve positron emission tomography (PET).