Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750), and administration 
(90471) provided on July 21, 2022. 
 
You asked the Plan to pay for the immunization. You say that you were advised by your doctor's office that this 
would be covered if you had it done at the office. You say that you cannot afford to pay for this. You also say 
that you feel this should be covered. The Plan denied your request. The Plan says the immunization is not 
covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750), and 
administration (90471) provided on July 21, 2022.  
 
Benefits for the immunization may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power operated vehicle (three- or four-wheel 
nonhighway) (E1230). 
 
You asked the Plan to pre-approve the power operated vehicle. You say that say the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for a Group 1 standard Power operated vehicle. 
 
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 operated vehicle. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support that the enrollee has a mobility deficit 
that impairs MRADLs in the home and this mobility limitation is not ameliorated by a walker, cane, manual wheelchair. While the enrollee may have the cognition to safely operate the requested power operated vehicle 
the documentation does not reveal a home assessment to support that the requested device will be able to safely 
maneuver in the home and access rooms for MRADL participation. The documentation does not support that 
the requested power operated vehicle will significantly improve the patients ability to participate in MRADLs 
and the enrollee will use it in the home. The documentation does not reveal that the requested power operated 
vehicle is 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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the power operated vehicle (three- or four-wheel nonhighway) (E1230).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) 
(78830). 
 
You asked the Plan to pre-approve SPECT. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet coverage criteria. 
 
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 SPECT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SPECT is not considered necessary to monitor small renal masses. The follow-up protocol most 
commonly used includes enhanced abdominopelvic computed tomography scanning. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve single photon emission computed tomography (SPECT) (78830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional incontinence pads. 
 
You asked the Plan to pre-approve additional incontinence pads. You say that you need one additional box. The 
Plan denied your request. The Plan says the documentation does not support the need for additional amounts of 
this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a physician order for additional supplies. The documentation does not include a 
written prescription signed and dated by your doctor for the requested items. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pre-approve additional incontinence pads.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 radiofrequency ablation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the criteria requires diagnostic 
medial branch blocks (MBBs) achieve 80% pain relief on both sets of diagnostic blocks. This was not achieved 
and 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RhinAer procedure. 
 
You asked the Plan to pre-approve a RhinAer procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a RhinAer procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has hypertrophy of nasal turbinates, chronic rhinitis, and 
hypertrophy of nasal turbinates causing chronic rhinitis and nasal obstruction. There is insufficient literature to 
support the safety and efficacy of the requested procedure for the enrollee's clinical condition at this time. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. 
 
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 RhinAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a RhinAer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination shower chair and commode chair. 
 
You asked the Plan to pre-approve a combination shower chair and commode chair. You say that this item is 
medically necessary. The Plan denied your request. The Plan says it has already provided you with a commode 
chair, and the shower chair component of the requested equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
You requested a combination shower chair and commode chair.  The Plan has confirmed that it provided you 
with a commode chair in 2018. While the shower chair component may be appropriate in this case, neither the 
Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-
approve a combination shower chair and commode chair.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on September 29, 2021. 
 
You asked the Plan to pay for the x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the chest x-ray (71045) provided on September 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on March 25, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care provided on March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac nerve. 
 
You asked the Plan to pre-approve the RFA for sacroiliac nerve. You say that the enrollee has had two 
successful lateral nerve blocks. You also say that this service will provide the enrollee with longer lasting pain 
relief. 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 the RFA for sacroiliac nerve. Our 
reviewer says that the requested the RFA for sacroiliac nerve is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental or investigational 
procedure because of the wide variation in efficacy reported in the literature. Therefore, the request RFA is 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 RFA for sacroiliac nerve have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac nerve.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Crysvita. 
 
You asked the Plan to pre-approve Crysvita. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Crysvita. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of x-linked familial hypophosphatemia/rickets. The record does not 
indicate that the active vitamin D analogs the enrollee is receiving will be discontinued one week prior to 
initiation of treatment. The Food and Drug Administration has not stated that the requested drug is indicated for 
the enrollee's condition. 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 Crysvita have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Crysvita.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88311 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 88311. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88311 is 4. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88311 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88311 billed for date of service May 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane injections. 
 
You asked the Plan to pre-approve Durolane. You say that Durolane is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that 
Durolane is not medically necessary. Our physician reviewer found the records in this case indicate the patient 
has left knee pain with crepitus and grinding, but no imaging studies are provided to confirm the diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the prostate surgery performed on July 
25, 2022, in Mexico. 
 
You asked the Plan to provide reimbursement for the surgery at issue. You say that this procedure was needed 
as an emergency. The Plan denied your request. The Plan says there is not sufficient evidence to support this 
was an emergency surgery. Elective treatments provided outside of the US are not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not generally made for services 
provided outside of the US. The Plan offers a supplemental benefit which applies only to emergency/urgently 
needed services.   
 
We looked at the file and Medicare rules. There is no medical documentation submitted to support your 
allegation that these services were required in an emergency. This would usually be a scheduled, elective 
procedure which is not covered under the Plan's worldwide benefit. Based on this information, we decided that 
Medicare rules for coverage of the surgery at issue have not been met. Therefore, we decided that the Plan does 
not have to provide reimbursement for the prostate surgery performed on July 25, 2022, in Mexico.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 CGM sensor. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee is not on insulin and therefore, does not meet 
coverage criteria for approval of the requested sensor. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre Kit 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre Kit 2 continuous glucose monitor (CGM) sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro range of motion assist device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational items are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that MyoPro Orthosis is not known to be effective, based on scientific evidence, professional standards 
and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this patient's 
condition or in widespread use for this patient's condition based on scientific evidence. There is insufficient 
evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient. There 
is insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro range of motion assist device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coude catheters. 
 
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 criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Coude catheters are covered when the beneficiary has 
had distinct, recurrent urinary tract infections, while on a program of sterile intermittent catheterization with 
A4351/A4352 and sterile lubricant A4332, twice within the 12-month prior to the initiation of sterile 
intermittent catheter kits.  
 
We looked at the file and Medicare rules. The records show that you have not had distinct, recurrent urinary 
tract infections while using sterile intermittent cathetierzation and lubricant twice within a 12-month period. 
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 Coude catheters.