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

 
We decided that the Plan does not have to pre-approve the Botox 200-unit vial. 
 
You asked the Plan to pre-approve the Botox 200-unit vial. You say that the drug is medically necessary. The 
Plan denied your request. The Plan says the enrollee's provider has indicated that this drug is being dispensed 
by a pharmacy- a Part D covered event. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve the Botox 200-unit vial.  
 
Benefits for the Botox 200-unit vial 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 Gemtesa 75MG Tablet. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is in need of Gemtesa 75MG 
Tablet for the treatment of an overactive bladder with incontinence. The Plan denied your request. The Plan 
says the medication is a self-administered drug and it not covered under Medicare Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa 75MG Tablet.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional occupational therapy visits 
 
You asked the Plan to pre-approve the therapy services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly, an 
additional 4 visits is not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested occupational therapy is generally accepted as a specific 
and effective therapy for the enrollee's impaired ability to perform daily activities after suffering a traumatic 
brain injury. The most recent documentation indicates that the enrollee is making progress with occupational 
therapy but continues to have deficits with activities of daily living, including dressing himself. He has 10 total 
visits of occupational therapy remaining, which should be sufficient now. Continued therapy can be considered 
if the enrollee shows documented objective improvement with treatment. 
 
Therefore, the 4 visits of additional occupational therapy cannot be considered 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional occupational therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair standard, captains chair, 
patient weight capacity up to and including 300 pounds (K0823) power wheelchair accessory, U-1 sealed lead 
acid battery, each (E2365) wheelchair accessory, adjustable height, detachable armrest, complete assembly, 
each (E0973). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are appealing with updated 
documents to prove medical necessity The Plan denied your request. The Plan says the records do not support 
that the enrollee meets the medically necessary criteria. 
 
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. 
 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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is able to perform mobility associated ADLs and is able to walk up and 
down stairs. There is no evidence the enrollee requires a power wheelchair 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 2 power wheelchair standard, captains chair, patient weight capacity up 
to and including 300 pounds (K0823) power wheelchair accessory, U-1 sealed lead acid battery, each (E2365) 
wheelchair accessory, adjustable height, detachable armrest, complete assembly, each (E0973).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on September 23, 2022. Comparison of the two claims shows these are exact duplicates. There is 
no evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93770 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 93770. The Plan denied your request. The Plan says procedure 
code 93770 is 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 code 93770 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 93770 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 93770 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 93770 billed for date of service May 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of an insertable loop recorder (33285). 
 
You asked the Plan to pre-approve implantation of an insertable loop recorder. You say that the requested 
service 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 implantation of an insertable loop 
recorder. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that while the enrollee has a history of atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an insertable loop recorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of an insertable loop recorder have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of an insertable loop recorder (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 11721. The Plan denied your request. The Plan says payment for 
code 11721 is bundled into payment for code 11055.  
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the office services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says there are in-network provider(s) within a reasonable distance from the 
enrollee's location that can provide this service or item. 
 
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 
the office services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve follow-up audiology services related to a cochlear 
implant to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON audiology services. You say that you believe that the enrollee 
needs to be seen by the provider who placed the cochlear implant. The Plan denied your request. The Plan says 
the necessary follow-up consultations and potential adjustments can be provided by equally qualified providers 
in the Plan's network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON audiology services. Our reviewer says that the documentation 
does not support that the requested OON provider is medically reasonable and necessary at this time. Our 
physician reviewer found the record indicates that the enrollee has a cochlear implant and requires audiology services. The medical record provided does not indicate that the Plan's providers are unavailable or inadequate 
to meet the enrollees medical needs. The elements of the coverage criteria are not satisfied.  
 
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 OON audiology services have not been met.  
 
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 the OON audiology services. Therefore, we decided 
that the Plan does not have to pre-approve follow-up audiology services related to a cochlear implant to be 
provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the intracept procedure is medically 
necessary and supported by strong science. The Plan denied your request. The Plan says there is little evidence 
in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. 
 
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 intracept 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is 
needed. 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 intracept procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the requested seat lift mechanism is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a seat 
lift mechanism. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer 
says that the enrollee does not meet criteria for a seat lift mechanism. Our physician reviewer found a seat lift 
mechanism is covered if an individual has severe arthritis of the hip or knee or has a severe neuromuscular 
disease. The seat lift mechanism must be a part of the treating practitioners course of treatment and be 
prescribed to effect improvement, or arrest or retard deterioration of the beneficiarys condition. Additionally, the beneficiary must be completely incapable of standing up from a regular armchair or any chair in their home. 
Once standing, the beneficiary must have the ability to ambulate. In this case, the documentation doesnt 
indicate that the member has severe neuromuscular disease or that they are incapable of standing up from a 
regular armchair or any chair in their home. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level and each 
additional level (CPT code(s): 64483 and 64484). 
 
You asked the Plan to pre-approve the injections. You say that the services are necessary. The Plan denied your 
request. The Plan says the notes do not show a pain scale and the notes do not show the enrollee is doing an 
exercise program. 
 
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 injections. Our physician reviewer 
found the enrollee has mild symmetric demyelinating polyneuropathy which is not a covered indication. 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level and each additional level (CPT code(s): 64483 and 
64484).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint and each additional 
facet join (CPT code(s): 64635 and 64636). 
 
You asked the Plan to pre-approve the injections. You say that the injections are necessary. The Plan denied 
your request. The Plan says the notes do not provide any information on the enrollee's pain relief from the last 
injection, and this must be provided to show the need for more procedures to be approved. 
 
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 injections. Our physician reviewer 
found there is no documentation of the percentage and duration of pain relief achieved. There is no 
documentation of a second confirmatory set of MBBs. The request does not meet the requirements of the LCD 
and therefore, is deemed not medically reasonable and 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, single facet joint and each additional facet join (CPT code(s): 64635 and 
64636).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on April 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that the report supports medical necessity. The Plan 
denied your request. The Plan says it cannot be determined how the enrollee came to the servicing provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. In this case, there are insufficient medical records from the enrollees 
treating physician to show that the testing was ordered for a specific medical problem. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on April 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of cranial nerve (eg, vagus nerve) 
neurostimulator electrode array and pulse generator (CPT code 64568). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are considered experimental and 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the efficacy of vagus nerve stimulation (VNS) for treating depression remains unclear. 
Significant improvement was seen in 27% of patients that received VNS vs. 13% that did not. VNS is not a 
rapid treatment for depression. Studies show that, on average, it may take up to 9 months for a treatment 
response to occur. The review has determined that the items/services at issue in this case are 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and 
pulse generator (CPT code 64568).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component (TC) of the intraoperative 
neuromonitoring (IONM) services provided on March 28, 2022. 
 
You asked the Plan to pay for the TC of the IONM services. You say that the equipment and technicians are 
supplied by you, and not the hospital. You state that this means that you must be paid directly for these items. 
The Plan denied your request. The Plan says non-physician services and equipment must be provided under 
arrangements by the facility. No separate payment is made to the supplier for these services.  
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
Although these services may be appropriate, payment for them is made to the hospital which must then furnish 
these services either directly or under arrangements. As such, separate Medicare payment cannot be made for 
the services at issue. Therefore, we decided that the Plan does not have to pay for the technical component (TC) 
of the intraoperative neuromonitoring (IONM) services provided on March 28, 2022.