Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the 
enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there 
are no issues for which LTACH may offer a therapeutic advantage. 
 
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 medical record does not indicate that the enrollee requires services that the 
enrollee is not currently receiving but that would be available at the LTACH facility. 
 
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 lower extremity prosthesis. 
 
You asked the Plan to pre-approve lower extremity prosthesis. You say that  The Plan denied your request. The 
Plan says  
 
The Plan agreed to pre-approve lower extremity prosthesis. Therefore, there is no need for a coverage decision. 
 Therefore, we decided that the Plan does not have to pre-approve lower extremity prosthesis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous neuromodulation therapy (PNT). 
 
You asked the Plan to pre-approve PNT procedure. You say that this procedure is needed to address the 
enrollee's condition. The Plan denied your request. The Plan says this procedure is 
experimental/investigational. 
 
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 PNT procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational approach. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PNT procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous neuromodulation therapy (PNT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sip and puff interface, power seat elevation system, base 
wedge, lateral spot pads, fusion display and programmer, customer specified dimensions, and power elevation 
leg. 
 
You asked the Plan to pre-approve sip and puff interface, power seat elevation system, base wedge, lateral spot 
pads, fusion display and programmer, specified dimensions, and power elevation leg. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested sip and puff interface is a 
second controller for a single power wheelchair. The documentation shows that the enrollee has successful trial 
of head control. A head control or extremity control interface has already been approved. There is no 
documentation that the enrollee has used a sip and puff control. A second controller for a single power 
wheelchair exceeds the enrollees needs and is not covered. Power seat elevation systems are specifically not 
covered. 
 
The approved cushions are all inclusive. The requested base wedge is not covered as it is unbundled. 
The requested lateral spot pads are switches that are already included with the approved controller. These items 
should not be requested separately. The approved head control includes all electronics needed to work properly. 
The requested electronics cannot be requested separately. The requested customer specified dimensions do not 
serve a medical need and cannot be covered. The documentation does not show why standard pads cannot be 
used. 
 
Based on this information, we decided that Medicare rules for coverage of sip and puff interface, power seat 
elevation system, base wedge, lateral spot pads, fusion display and programmer, specified dimensions, and 
power elevation leg have not been met. Therefore, we decided that the Plan does not have to pre-approve sip 
and puff interface, power seat elevation system, base wedge, lateral spot pads, fusion display and programmer, 
customer specified dimensions, and power elevation leg.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography, head or brain provided on  
June 30, 2022. 
 
You asked the Plan to pay for the computed tomography, head or brain. The Plan denied your request. The Plan 
says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated 
to the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a computed tomography, head or brain provided on  
June 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this medication helps improve your quality of life. 
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 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 Zilretta. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found you have a diagnosis of osteoarthritis of the left knee. You previously received Zilretta 32mg 
injections in the left knee on October 25, 2021, March 7, 2022 and July 8, 2022. The efficacy and safety of 
repeat administration of Zilretta have not been demonstrated. Therefore, you do not meet 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of one knee cartilage using endoscope 
(29881). 
 
You asked the Plan to pre-approve the removal of one knee cartilage using endoscope. You say that the service 
is medically necessary. The Plan denied your request. The Plan says the service 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 the removal of one knee cartilage using 
endoscope. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the clinical effectiveness of arthroscopic lavage and 
arthroscopic debridement for the severe osteoarthritic knee has not been verified by scientifically controlled 
studies. After thorough discussions with clinical investigators, the orthopedic community, and other interested 
parties, CMS determines that the following procedures are not considered reasonable or necessary in treatment 
of the osteoarthritic knee and are not covered by the Medicare program. 
 
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 removal of one knee cartilage using endoscope have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the removal of one knee cartilage using 
endoscope (29881).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are 
network providers that can provide 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
oncology services to be provided by an out-of-network (OON) provider.
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 a good candidate for rehabilitation in order 
to regain independence. The Plan denied your request. The Plan says the IRF services you 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee would benefit from therapy services, medically necessary care can be provided in a different level of 
care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device (E0470). 
 
You asked the Plan to pre-approve a respiratory assist device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that an E0470 device is covered if the criteria listed in the 
Medicare Rules section is 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 a respiratory assist device. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found the provided records do 
not document an arterial blood gas PaCO2, done while awake and breathing the beneficiary's prescribed FIO2, 
of greater than or equal to 52 mm Hg. 
 
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 respiratory assist device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a respiratory assist device (E0470).
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 you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for open or percutaneous endovascular revascularization of a 
unilateral femoral or popliteal artery, with atherectomy, including angioplasty within the same vessel, when 
performed (37225) and Angiography, extremity, unilateral, radiology supervision and interpretation (75710) 
provided August 25, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that please review attached reports to support 
medical necessity for procedures performed. Please reprocess. The Plan denied your request. The Plan says the 
records do not support the service billed and 75710 as inclusive to the primary procedure and cannot be 
approved separately. 
 
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 37225 is open or percutaneous endovascular 
revascularization of a unilateral femoral or popliteal artery, with atherectomy, including angioplasty within the 
same vessel, when performed and 75710 is angiography, extremity, unilateral, radiology supervision and 
interpretation.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the surgical procedure. Our reviewer says that the Medicare 
criteria for coverage was not met. Our reviewer found the medical records provided does not include sufficient 
documentation to validate that an open or percutaneous endovascular revascularization of a unilateral femoral 
or popliteal artery, with atherectomy, including angioplasty within the same vessel, when performed was 
performed on August 25, 2022. 
 
We have also confirmed that payment for code 75710 is bundled into the payment to the primary procedure and 
cannot be approved separately. This claim has not been billed with an appropriate modifier to bypass the edit.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for open or percutaneous endovascular revascularization of a unilateral femoral or 
popliteal artery, with atherectomy, including angioplasty within the same vessel, when performed (37225) and 
Angiography, extremity, unilateral, radiology supervision and interpretation (75710) provided August 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute knee walker (E0118). 
 
You asked the Plan to pre-approve a crutch substitute knee walker. You say that the item is medically 
necessary The Plan denied your request. The Plan says this item is not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute knee walker 
(E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ESI is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee had a previous ESI on 
December 16, 2022 that did not provide at least 50 percent sustained improvmenet in pain relief and/or 
function for at least three months. The criteria for coverage are not met and the repeat ESI is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablets. 
 
You asked the Plan to pre-approve ondansetron. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this drug is not covered by Medicare Part B under the circumstances. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although ondansetron is an oral anti-emetic that may be covered by Medicare Part B, the 
requested use does not fall within the circumstances for coverage because the record does not show that this 
drug will be initiated within 2 hours of chemotherapy for a period not to exceed 48 hours. Therefore, we 
decided that the Plan does not have to pre-approve ondansetron tablets.  
 
Benefits for ondansetron 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding electric AirHawk power chair (K0899). 
 
You asked the Plan to pre-approve the power chair. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says The electric AirHawk power 
chair is not a brand that is covered by the Plan. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the electric AirHawk power chair is not a brand covered by the Plan. Also, you stated you are requesting the AirHawk folding power wheelchair in order to fit inside your care for outdoor use. If a brand 
that is not available through the CarePlus is 
requested, your treating practitioner must document that the brands available through CarePlus are not able to 
meet your mobility needs. The Plan made multiple attempts to contact your PCP without success.. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a folding electric AirHawk power chair (K0899).