Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 1, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that you want the Plan to pay for the services. 
The Plan denied your request. The Plan says the provider is out-of-network and there was no authorization for 
the 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 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 physical therapy services provided on September 
1, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression procedure. 
 
You asked the Plan to pre-approve a minimally invasive lumbar decompression procedure. You say that a 
minimally invasive lumbar decompression procedure is medically necessary. The Plan denied your request. 
The Plan says a minimally invasive lumbar decompression procedure does not meet the Medicare NCD 
coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 minimally invasive lumbar 
decompression procedure. Our reviewer says that a minimally invasive lumbar decompression procedure is not 
medically necessary. Our physician reviewer found the enrollee is not enrolled in a clinical trial assessing the MILD procedure. The enrollee does not meet the Medicare NCD criteria and the request 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 a minimally invasive lumbar decompression procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression 
procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that you are requesting a CGM 
for the enrollee to better control their insulin. The Plan denied your request. The Plan says the enrollee does not 
require insulin three or more times daily. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a therapeutic CGM and supplies.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation for pain management appointments. The Plan denied your request. The Plan says the requested 
trip exceeds the Plan's mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each trip does not exceed 50 miles of driving distance.  
 We looked at your request, the records in the case file, and the rules. The requested trip exceeds 50 miles of 
driving distance. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you are requesting a continuous glucose 
monitoring system for the enrollee. The Plan denied your request. The Plan says the enrollee does not require 
insulin three or more times daily. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that this device is necessary to help the 
enrollee get around. The Plan denied your request. The Plan says the records do not show the results of an on-
site evaluation of the home to verify the enrollee can use the device. 
 
The Plan follows Medicare rules. Medicare rules say that a POV will be covered if the beneficiarys home 
provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is 
provided.  
 
The file shows does not include the results of an on-site evaluation of the home to verify the enrollee can use 
the device. 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 power operated vehicle, group 1 standard, patient weight capacity 
up to and including 300 pounds (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a permanent cardiac contractility modulation system 
procedure (code 0408T). 
 
You asked the Plan to pre-approve a permanent cardiac contractility modulation system procedure. You say 
that a permanent cardiac contractility modulation system procedure is medically necessary. The Plan denied 
your request. The Plan says the requested permanent cardiac contractility modulation system procedure is 
experimental. 
 
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 a permanent cardiac contractility 
modulation system procedure. Our reviewer says that the requested permanent cardiac contractility modulation 
system procedure is not considered medically reasonable and necessary. Our physician reviewer found the 
Optimizer Smart System would currently be considered investigational. There is insufficient evidence of a role 
for this system in management of heart failure with reduced ejection fraction in the professional guidelines.  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 permanent cardiac contractility modulation system procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a permanent cardiac contractility 
modulation system procedure (code 0408T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Posterior Tibial Nerve Stimulation (PTNS) (64566). 
 
You asked the Plan to pre-approve a PTNS. 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 National Government Services (NGS) will allow 
PTNS coverage for beneficiaries with overactive bladder syndrome (OBS) as a less invasive third-line 
treatment for selected patients who meet the criteria outlined 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 a PTNS. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found PTNS is an appropriate third line treatment 
when an individual has failed first- and second-line treatments. In this case, the records do not show that the 
enrollee has failed pelvic floor exercise/behavior modification or a trial of at least two appropriate medications 
administered for four (4) to eight (8) weeks. 
 
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 PTNS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Posterior Tibial Nerve Stimulation (PTNS) (64566).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0005) and accessories. 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover DME in a long-term care 
facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a manual wheelchair (K0005) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous 
stabilization device (22869). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that interlaminar stabilization devices are experimental in spinal surgery. High failure rates have been 
reported. 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of an interlaminar/interspinous stabilization device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4215 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code A4215. 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 A4215 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4215 is statutorily excluded from payment. Based on this information, we decided that Medicare rules for coverage of procedure code A4215 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4215 billed for date of service September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RACZ injection. 
 
You asked the Plan to pre-approve a RACZ injection. You say that a RACZ injection is medically necessary. 
The Plan denied your request. The Plan says a RACZ injection 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 a RACZ injection. Our reviewer says 
that the requested RACZ injection is not considered medically reasonable and necessary. Our physician 
reviewer found that the role of a RACZ catheter to treat spinal stenosis or epidural lipomatosis is considered 
experimental. Therefore, the request 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 a RACZ injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a RACZ injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of exudative age-related macular degeneration, left eye. The documentation 
does not support that the enrollee has tried the ophthalmic formulation of bevacizumab. The documentation 
does not support that the ophthalmic formulation of bevacizumab would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total knee arthroplasty (27447). 
 
You asked the Plan to pay for a total knee arthroplasty. 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 pay for a total knee arthroplasty. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures (plausibly including viscosupplementation injections.) 
Moreover, there are no formal diagnostic imaging studies provided to corroborate osteoarthritis of the left knee 
that is severe enough to require surgical intervention. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pay for a total knee arthroplasty (27447).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's care needs require daily 
specialized physician management for multiple medically complex issues. The Plan denied your request. The 
Plan says all services that would be provided in the LTACH are being provided in the current acute care setting 
which is already approved. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78830-59 billed for date of service August 
26, 2021. 
 
You asked the Plan to pay for procedure code 78830-59. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 78830-59 is bundled into 
payment for code 79101. 
 
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 
78830-59 is a column II code to column I code 79101 with a modifier indicator of 0. The column II code is therefore not payable. 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 78830-59 billed for date of service August 26, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair and accessories. 
 
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover durable medical equipment 
(DME) in a long-term care facility (LTCF). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says you do not meet the criteria for approval. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.