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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that a standard wheelchair cannot 
provide the required level of independence. The Plan denied your request. The Plan says the enrollee does not 
require multiple power options 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are only covered under certain 
medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested wheelchair. Our physician 
reviewer found that the enrollee has chronic demyelinating polyneuritis. The enrollees condition does not meet 
criteria for multiple power drives as he is not at high risk for skin breakdown. He has no wounds and has been 
in a wheelchair for 10 years. He does not use intermittent catheterization and does not have spasticity. 
Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Because the base wheelchair is not covered, 
the related requested accessories are not covered. Based on this information, we decided that Medicare rules for 
coverage of the requested wheelchair have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the enrollee has tried and failed Sanctura and 
Myrbetriq. You also say that the enrollee has had the best results and relief with Gemtesa. The Plan denied 
your request. The Plan says Gemtesa is a self-administered drug, and does not fall under 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.  
 
Benefits for Gemtesa 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an image-less computer-assisted surgical navigational 
procedure. 
 
You asked the Plan to pre-approve the services. You say that the records provided support the need for the 
services in dispute. The Plan denied your request. The Plan says the evidence is lacking and large population 
sufficiently powered randomized controlled trials that demonstrate long-term health outcome advantages are 
needed. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that computer navigation surgery has not been shown to produce better outcomes and has not been 
shown to be more effective than conventional open joint surgery. 
 
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 an image-less computer-assisted surgical navigational procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reduction forehead; contouring & setback, anterior 
frontal sinus wall (21139 x2), genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or 
bone wedge reversal for asymmetrical chin) (21122) grafting of autologous fat harvested by liposuction 
technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc 
injectate, or part thereof (15774) and osteoplasty, facial bones; reduction (21209). 
 
You asked the Plan to pre-approve reduction forehead, genioplasty, grafting of autologous fat harvested by 
liposuction technique, and osteoplasty. You say that the services are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 reduction forehead, genioplasty, 
grafting of autologous fat harvested by liposuction technique, and osteoplasty. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that you have transitioned for over twenty years. The record 
notes that you have gender dysphoria but also indicates that the treatment is to improve appearance and is 
cosmetic in nature. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not 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 reduction forehead, genioplasty, grafting of autologous fat harvested by 
liposuction technique, and osteoplasty have not been met. Therefore, we decided that the Plan does not have to 
pre-approve reduction forehead; contouring & setback, anterior frontal sinus wall (21139 x2), genioplasty; 
sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical 
chin) (21122) grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, 
orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (15774) and osteoplasty, 
facial bones; reduction (21209).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia. 
 
You asked the Plan to pre-approve Kerendia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
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 Kerendia.  
 
Benefits for Kerendia 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on June 1, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 drug testing provided on June 1, 2022, by an out-
of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that continued admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that SNF care is no longer medically necessary. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require any skilled services on an inpatient basis. The 
physician reviewer also found that the enrollee's function was at or near her prior level of function and can be 
discharged to a lower level of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this 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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental, and 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) provided on April 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a medical eye examination (92014). You say that a provider performing services 
in a nursing facility is not responsible to obtain authorization. You also say that the visit should fall under the 
authorization that the nursing home has for the stay of the patient. The Plan denied your request. The Plan says 
this provider is out-of-network with the Plan. The Plan also says that authorization was not obtained prior to the 
services being rendered. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 a medical eye examination (92014) provided on 
April 20, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-FACTOR allograft. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of i-FACTOR allograft in the setting of a lumbar 
fusion procedure have not been demonstrated in the peer-reviewed literature. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the health plan has approved a L2-3 extreme lateral interbody fusion, L2-3 left robotic assisted 
posterior spinal fusion. However, there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the request for is not medically reasonable or necessary.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve i-FACTOR allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2. 
 
You asked the Plan to pre-approve the Freestyle Libre 2. You say that the records provided should support the 
necessity of the requested service The Plan denied your request. The Plan says the enrollee is not on insulin and 
does not meet all of the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre 2 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 2.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 24, 2021. 
 
You asked the Plan to pay for ambulance services. You say that these services are related to third party 
liability. The Plan denied your request. The Plan says these services were paid for in full by the primary payer. 
 
The Plan must follow Medicare rules. The rules state when Medicare is the secondary payer, the provider or 
enrollee must first submit the claim to the primary payer. If the primary payer does not pay in full for the 
services, Medicare secondary benefits may be paid. 
 
The record shows that the primary payer paid in full for the services at issue. Therefore, we decided that the 
Plan does not have to pay for ambulance services provided on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure due to chronic obstructive pulmonary disease (COPD). 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 bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate. A ventilator is not covered 
for BiPAP and 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 home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum-assisted socket system (VASS). 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider's notes do not show an increase or change in activity level that would 
support the need for these special features. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the literature reviewed indicates that further research is needed with clinical trials that recruit larger 
sample sizes and report long-term outcome data for the requested elevated vacuum suspension system. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vacuum-assisted socket system (VASS).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pre-approve ambulance transportation. 
 
You asked the Plan to pre-approve ambulance transportation. You say that you need transportation to your 
appointments. The Plan denied your request. The Plan says that a physician's office is not a covered 
destination. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transport to a destination that is 
equipped to treat the condition is covered. 
 
We looked at the file and Medicare rules. Transportation to physician offices is covered during the Covid-19 
public health emergency. Based on this information, we decided that Medicare rules for coverage of have been 
met. Therefore, we decided that the Plan has to pre-approve ambulance transportation.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller for an approved power 
wheelchair (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the expandable controller. You say that these features are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller. Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found the requested 
electrical accessories are not medically necessary as the enrollee does have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic 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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller for an approved power wheelchair (E2311, E2313, 
E2377).