Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee suffers from chronic 
hypercapnic and hypoxic respiratory failure. For the severity of her respiratory status, the enrollee was setup on 
a home trilogy machine to maximize safe and adequate ventilation with AVAPS-AE. The enrollee is already 
dependent on four liters of supplemental oxygen at home, she has depressed systolic heart function, and has 
had a declining quality of life over the years due to dyspnea, fatigue, and the inability to perform daily 
activities. The Plan denied your request. The Plan says the records do not show that you have failed treatment 
with CPAP or BIPAP or that the requested NIV will not be used exclusively in CPAP or bi-level PAP mode. 
 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to obesity hypoventilation syndrome and obstructive sleep apnea with a 
history of lupus and pulmonary embolism.  Provided records document that the home ventilator is being 
requested for use in average volume assured pressure support (AVAPS) mode with auto-titration (AE) which 
could be provided by a BiPAP device with AVAPS and a back-up rate. Provided records do not document trial 
and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 you have had this drug before and it worked fine. You 
also say that you cannot afford to pay for this. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
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 Plan requires documentation of a 
diagnosis of postmenopausal osteoporosis with a T-score of less than or equal to -2.5 or a history of a fragility 
fracture and a trial of one oral bisphosphonate and one intravenous bisphosphonate before they will approve the 
requested drug, Prolia. The reviewer found that the provided records do not indicate a diagnosis of 
postmenopausal osteoporosis with a T-score of less than or equal to -2.5 or a history of a fragility fracture. The 
reviewer found that the enrollee has not tried and failed oral or intravenous bisphosphonates. The reviewer also 
found there is no indication that the plan's required drugs 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. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Stab Phlebectomy 10-20 stab incisions (37765) and 
Stab Phlebectomy more than 20 incisions (37766). 
 
You asked the Plan to pre-approve the Stab Phlebectomy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments for symptomatic varicose tributaries are 
either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 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 Stab Phlebectomy. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the health plan does not provide for simultaneous treatment of tributary veins at the time of truncal (saphenous) reflux treatment. A rationale for 
this is that many patients experience satisfactory relief of symptoms following saphenous reflux treatment 
alone. The health plan requires that, for stab phlebectomy to be approved, there needs to be demonstration of 
persistent significant symptoms despite use of compression stockings for at least six weeks after the saphenous 
reflux is treated, and that the veins be 4mm or greater in diameter. The saphenous reflux has not yet been 
treated and the largest tributary vein is less than 4mm in diameter. 
 
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 Stab Phlebectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Stab Phlebectomy 10-20 stab incisions (37765) and Stab Phlebectomy more 
than 20 incisions (37766).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urological supplies to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee has been using services with you 
since 2015. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON items. Therefore, we decided that the Plan does not have to pre-approve urological 
supplies to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair (K0005). 
 You asked the Plan to pre-approve an ultra-lightweight manual wheelchair. 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 ultra-lightweight manual wheelchair (K0005) is 
covered for a beneficiary if the criteria 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 an ultra-lightweight manual wheelchair. 
Our reviewer says that the member does not need this item. Our physician reviewer found the provided records 
do not document the patient requires individualized fitting and adjustments for one or more features such as, 
but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be 
accommodated by a K0001 through K0004 manual wheelchair. They also not document the patient has had a 
specialty evaluation as detailed above recommending the ultra-lightweight wheelchair in addition to the power 
scooter and transport chair.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultra-lightweight manual wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair (K0005).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the eyewear provided on May 18, 2022.
You asked the Plan to provide additional payment for the eyewear. You say that that you did not receive any services on May 18, 2022. The Plan denied your request. The Plan says that you have met the $200 maximum yearly vision allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says that you have a $200 allowance for supplemental eyewear every year and you are responsible for all costs over and above the allowance amount. We looked at the file and the Plan's rules. The total cost charged for the eyewear was $350. The Plan then paid $200 leaving $150. A 20% discount ($30) was then applied leaving a balance of $120 that you are responsible for. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to provide additional payment for the eyewear provided on May 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 3, 2022.
You asked the Plan to pay for the ambulance services. You say that this service was necessary. The Plan denied your request. The Plan says that this service is not covered when there is no transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 3, 2022. The ambulance benefit is a transportation benefit.
When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve injections. You say that you have been treating the enrollee's chronic 
multifactorial low back pain. You also say that the enrollee has done the appropriate physical therapy. The Plan 
denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet certain 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 injections. Our reviewer says that the 
requested injections are not medically necessary. Our physician reviewer found there is no documentation of 
the degree of pain relief from the prior medial branch blocks (MBBs) provided.  The reviewer found that there 
is no information provided as to why the enrollee is not a candidate for radiofrequency ablation (RFA), as the 
enrolee had MBBs in 2015 at the same spinal levels. Therefore, the reviewer found that the requested injections 
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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve facet joint injections (64493, 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96574) provided on March 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the requested services (96574) is included in the global 
surgery payment for the procedure (27327) provided on the same date. 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 pay for the services (96574) provided on March 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous decompression 
spacer procedure (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the Vertiflex procedure is considered 
safe and effective, as supported by its clinical benefits to patients, continued medical professional adoption and 
strong clinical evidence with numerous peer reviewed studies. The Plan denied your request. The Plan says 
there are not enough studies on Vertiflex Superion to show it is safe and effective. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex Superion interspinous decompression spacer procedure (22869, 
22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on December 19, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that the services are payable. The Plan denied 
your request. The Plan says prior authorization was not obtained for the billed service. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) provided on December 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), of diagnostic or therapeutic 
substance(s), not including neurolytic substances, including needle or catheter placement, interlaminar epidural 
or subarachnoid, lumbar or sacral caudal; with imaging guidance (62323). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESI's are medically necessary when 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 the epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has not 
been compliant with physical therapy or a home exercise program for conservative treatment of back pain.  In 
addition, there is specific documentation that he refuses involvement with physical therapy (PT) and/or a home 
exercise 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 epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the injection(s), of diagnostic or therapeutic substance(s), not including 
neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or 
sacral caudal; with imaging guidance (62323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory PCR (polymerase chain reaction) panel 
(87798, 87483, 87880, 87631) provided on November 10, 2022. 
 
You asked the Plan to pay for the respiratory panel. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test is not covered as it 
included more than five respiratory pathogens, and this is not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with more than five respiratory pathogens 
performed in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory panel have not been met. Specifically, the records show that this panel included 
testing for nine different pathogens. Therefore, this test is considered not medically necessary. Therefore, we decided that the Plan does not have to pay for the respiratory PCR (polymerase chain reaction) panel (87798, 
87483, 87880, 87631) provided on November 10, 2022.
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 can receive care in another setting after leaving the hospital. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute hospital with dyspnea secondary to volume overload 
in the setting of cirrhosis and chronic kidney disease. The record indicates that the enrollee is improving but 
still requires acute care services before transitioning to a lower level of care. The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that he is not currently receiving but that would be available at the LTACH facility. The 
elements of the coverage rules are not satisfied. The requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 13, 2022.