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

 
We decided that the Plan has to pre-approve epidural injection of the low back while you are asleep/under 
moderate sedation. 
 
You asked the Plan to pre-approve epidural injection of the low back while you are asleep/under 
moderate sedation. You say that epidural steroid injections with sedation are medically necessary. The Plan 
denied your request. The Plan says that epidural steroid injections with sedation do not meet the Medicare 
criteria. 
 
The Plan follows Medicare rules. Medicare rules say that occasional minimally to moderate conscious sedation 
is appropriate and if monitored anesthesia care is utilized the need for such stations should be clearly 
documented in the medical record. 
 
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 epidural injection of the low back while 
you are asleep/under moderate sedation. Our reviewer says that epidural injection of the low back while you 
are asleep/under moderate sedation are medically necessary. Our physician reviewer found that you have two 
psychiatric diagnoses that are reasonable for the need for sedation. The requested services are 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 epidural injection of the low back while you are asleep/under moderate sedation 
have been met. Therefore, we decided that the Plan has to pre-approve epidural injection of the low back while 
you are asleep/under moderate sedation. 
 
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 the power operated vehicle, group 1 heavy duty, patient 
weight capacity 301 to 450 pounds (CPT code K0801). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the information sent in does not show your provider's recent notes with details 
about why you need a scooter. The Plan states there is no home assessment completed showing the requested 
scooter would work in your home. The Plan states your provider must show medical need before this request 
can be approved and the notes sent in do not meet the rules. 
 
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 DME. Our physician reviewer 
found the documentation does not include a mobility evaluation with a physical therapist. There is no 
indication that you have been evaluated for safe use with regards to the requested scooter or that it will operate 
appropriately in your home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 450 pounds 
(CPT code K0801).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous remote monitoring of nervous system during 
operation (95941) provided on May 24, 2021. 
 
You asked the Plan to pay for continuous remote monitoring services. You say that this claim is supported as 
billed. The Plan denied your request. The Plan says this service was billed with a code that is not valid 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 CPT code. 
 
We find that CPT code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of continuous remote monitoring services have not been met. Therefore, we decided that the Plan 
does not have to pay for continuous remote monitoring of nervous system during operation (95941) provided 
on May 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous endoscopic laminectomy. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested percutaneous endoscopic 
laminectomy is considered experimental in nature, as more research is needed to show its safety and efficacy. 
The services are therefore 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 percutaneous endoscopic laminectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 2, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 3, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed in this case. 
 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 71045 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on December 3, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve only two (2) levels. We decided that the Plan does not have to pre-
approve a third level.  
 
You asked the Plan to pre-approve only two (2) levels. You say that the clinical information shows the 
enrollee's pain does radiate. The Plan says that the Medicare rules have not been met. 
 We decided that the Plan has to pre-approve only two (2) levels.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our physician reviewer 
found only two (2) levels are deemed medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have been met. Therefore, we decided that the Plan has to pre-
approve only two (2) levels.  
 
We also decided that the Plan does not have to pre-approve a third level. 
 
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 third level. Our physician reviewer 
found a third level exceeds utilization criteria.  
 
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 third level have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a third level. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (CPT code 
0421T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the medical necessity coverage criteria is not met per The Centers for 
Medicare & Medicaid Services (CMS) guidelines given that the enrollee has an IPSS score of 10 and the 
enrollees maximum urinary flow rate is 45.1 mL/s. 
 
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 service. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
Specifically, the enrollee has an IPSS score of 10 and the enrollee's maximum urinary flow rate is 45.1 mL/s. 
Also, the prostate size was not given in the records. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transurethral waterjet ablation of prostate (CPT code 0421T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on October 
20, 2021. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the documentation 
submitted did not include a valid physician order. 
 
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 valid physician order. 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 pay 
for the durable medical equipment (DME) provided on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller upgrade (E2377) harness (E2313) 
electronic connection between wheelchair controller and two or more power seating system motors (E2311) 
ram x-grip phone holder (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and phone holder. You say that the enrollee meets 
Medicare's criteria for power tilt and power recline as she is at high risk for pressure sores and is unable to 
perform an effective weight shift. The Plan denied your request. The Plan says the approved power options 
come with their own switches and there is no medical need to control these power options through the joystick. 
The phone holder does not serve a medical purpose. 
 
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 upgraded electronics and phone 
holder. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on the medical records provided there is no 
documentation that the expandable controller upgrade (E2377), harness (E2313) and electronic connection 
between wheelchair controller and two or more power seating system motors (E2311) meet the requirements 
listed in the LCD for Medicare coverage. Provided records document that the enrollee has 4/5 right upper 
extremity strength and is independent with grooming thus indicating she has adequate upper extremity strength 
and function to operate the wheelchair's power options with their own switches. 
 
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 upgraded electronics and phone holder have not been met. Therefore, we 
decided that the Plan does not have to pre-approve expandable controller upgrade (E2377) harness (E2313) 
electronic connection between wheelchair controller and two or more power seating system motors (E2311) 
ram x-grip phone holder (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-covered item, transit kit option (A9270). 
 
You asked the Plan to pre-approve transit kit. You say that the enrollee needs replacement of an ultra light 
manual wheelchair. The enrollee is unable to walk and is an active wheelchair user. The Plan denied your 
request. The Plan says the requested equipment does not meet the Medicare definition of DME as the transit 
system is for use outside the home. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transit kit have not been met. Therefore, we decided that the Plan does not have to pre-approve non-covered item, transit kit option (A9270).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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. Medicare rules say that Botox is covered when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of Botox injections, 800 units 
every three months to the hamstring complex for hereditary spastic paraplegia is not supported in the Medicare-
approved major drug compendia. Based on the medical records provided and the Medicare-approved major 
drug compendia, the services are 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 Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuromuscular stimulator, electronic shock unit 
(E0745). 
 
You asked the Plan to pre-approve a neuromuscular stimulator, electronic shock unit. You say that you already 
have a stimulator, and has had 3 of them, but you need one that is able to be plugged into a wall charger. You 
are unable to purchase batteries for these out of pocket and you prefer one to be chargeable in the wall. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 Neuromuscular stimulator, electronic 
shock unit. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is requesting a new nerve stimulator device 
(NMES) as the one he currently has no longer works. There is no authorization history noted for NMES. Per 
notes obtained, the enrollee with history of gunshot wound to C-spine in 1996 and power mobility device 
dependent. The enrollee does not meet criteria for NMES per Medicare NCD. The review has determined that 
the medical records provided do not meet the requirements listed in the NCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neuromuscular stimulator, electronic shock unit have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a neuromuscular stimulator, electronic shock unit 
(E0745).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7285) provided on 
December 2, 2021. 
 
You asked the Plan to pay for the incisional biopsy of oral tissue. You say that you believe this service is a 
surgical procedure, not a dental procedure, and should be covered. The Plan denied your request. The Plan says 
this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
incisional biopsy of oral tissue (D7285) provided on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2394) for tooth # 30 provided on December 15, 2021. 
 
You asked the Plan to pay for the dental service. You say that there were errors made in the processing of this 
claim. You say that the penalty you will have to pay is $453. You say that you were advised by the dental 
office that the services would all be covered at 100%. You also say that you would like this filling to be 
covered under you 2022 coverage. The Plan denied your request. The Plan says 2 fillings are covered per 
calendar year. The Plan also says that the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 2 fillings are covered per calendar 
year, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received 
on the date of service. Additionally, claims are processed based on the benefits available when they are received. 
Therefore, we decided that the Plan does not have to pay for the filling (D2394) for tooth # 30 provided on December 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the abdominoplasty with panniculectomy (15830, 
15847, 15734). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you need the surgery because you are a 
diabetic and has extra skin that causes problems including bad odor, sores and ulcers. The Plan denied your 
request. The Plan says this service is not covered for this stage of your medical condition. If you do not respond 
to medical therapy, surgery may be considered. 
 
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 surgical procedure. 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 the enrollee has a large pannus causing 
discomfort and rashes for twenty years. The record does not document the failure of conservative therapy. 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 the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the abdominoplasty with panniculectomy (15830, 15847, 15734).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a methylprednisolone dose pack. 
 
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 self-administered drugs are not covered. 
 
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 a methylprednisolone dose 
pack.  
 Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.