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

 
We decided that the Plan does not have to pre-approve an all-lower extremity prosthesis, flex-walk system or 
equal (L5981) and an all-lower extremity prosthesis, multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve advanced foot and ankle prosthetics. You say that your provider 
recommended you use the prosthetic material requested due to covered material not being good quality and 
satisfactory. You say the upgraded material will function much better. The Plan denied your request. The Plan 
says you do not meet medical necessity for a K3 foot since your activities prior to amputation were not 
consistent with K3 activity. Your physician does not document a need for a K3 component. 
 
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 advanced foot and ankle. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records from your physician do not support the prosthetist's 
assertion that you are a K3 level ambulator. Supplier-produced records, even if signed by the treating 
practitioner, and attestation letters are deemed not to be part of a medical record for Medicare payment 
purposes. Your medical record must contain sufficient documentation of your medical condition to substantiate 
the necessity for the type and quantity of items ordered and for the frequency of use or replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of advanced foot and ankle have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an all-lower extremity prosthesis, flex-walk system or equal (L5981) and an all-
lower extremity prosthesis, multi-axial rotation unit (L5986).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kimyrsa 1,200MG intravenous solution. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says because the Plan's criteria have not been met and the enrollee's provider has not 
demonstrated that it is medically necessary to make an exception for the enrollee, this request is not approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the review has determined that the requested use of Kimyrsa 1,200MG intravenous solution is not FDA-
approved for the enrollees diagnosis. Its use in this case is not supported by one of the major drug compendia 
or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical 
journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Kimyrsa 1,200MG intravenous solution.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99205, 99215) and consultations (88321, 
88323, 88325, 99449) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and consultations. You say that you have a rare form of breast 
cancer, and you need to be seen at the requested facility to get the appropriate consultation and possibly 
treatment. Due to the rareness of your cancer, you are uncertain if radiation therapy will be the best option and 
you would like to get a second opinion before proceeding. The Plan denied your request. The Plan says you 
must use network providers to get your medical care and services. There are in-network provider(s) within a 
reasonable distance from your location that can provide this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99205, 99215) and consultations (88321, 88323, 88325, 99449) to be provided by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level and second level (CPT code(s): 64493 and 64494). 
 You asked the Plan to pre-approve the injections. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records do not show how 
severe and debilitating their pain is, when their last facet injections were and how much relief these provided. 
 
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 there is no documentation of when or the effectiveness of the last facet injection. The review has 
determined that the medical records provided did not meet the requirements listed in the LCD 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level and 
second level (CPT code(s): 64493 and 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L-Dex, bioimpedance spectroscopy (CPT code 93702). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the use of L-Dex for measuring swelling (edema) has not been proven to be the standard 
of care. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found devices using bioimpedance (bioelectrical impedance spectroscopy) are considered 
investigational for use in the diagnosis, surveillance, or treatment of patients with lymphedema, including use 
in subclinical secondary lymphedema. The review has determined that the items/services at issue in this case 
are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L-Dex, bioimpedance spectroscopy (CPT code 93702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement folding walker (E0143) and seat 
attachment (E0156). 
 
You asked the Plan to pre-approve a replacement folding walker and seat attachment. You say that you 
disagree with the denial and are requesting reconsideration. The Plan denied your request. The Plan says your 
request is not medically necessary because your records show you have duplicate approval for the same 
request. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you were approved for a rollator walker with seat on June 17, 2019, exchanged it on August 
19, 2019, and then received another walker on November 20, 2020, and exchanged it in 2021. The file also 
shows that your doctor requested repair or replacement of your current device. A rollator walker with seat 
serves the same purpose as a replacement folding walker and seat attachment. Therefore, we decided that the 
Plan does not have to pre-approve a replacement folding walker (E0143) and seat attachment (E0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in intelligent volume-
assured pressure support (iVAPS) mode with Auto-expiratory positive airway pressure (EPAP) (AE) that could 
be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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 the home ventilator. Our physician 
reviewer found Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special power wheelchair with power tilt and 
accessories (K0835, E1028x2, E2359, E1012, E1002, E0955, E2311). 
 
You asked the Plan to pre-approve a special power wheelchair and accessories. You say that the enrollee has a 
medical history including cervical myelopathy with SCI compression. She requires mod to max assistance for 
all mobility and transfers due to UE limitations, pain, and poor endurance. The enrollee requires an 
appropriately configured group 2 PWC with power tilt for in home mobility, pressure relief and participation in 
MRADL. The Plan denied your request. The Plan says the requested PWC exceeds the enrollee's needs and is 
not reasonable and necessary, per Medicare criteria. 
 
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 a special power wheelchair and 
accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found there 
is documentation that the enrollee has a personal mobility deficit that impairs participation in mobility related 
activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within the 
home.  The enrollee's mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due 
to her level of weakness and instability. Provided records do not support that the enrollee is high risk for skin 
breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Records do not document the 
enrollee performs bladder self-catheterization and is unable to transfer independently or that she has increased 
muscle tone or spasticity. 
 
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 special power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a special power wheelchair with power tilt and accessories 
(K0835, E1028x2, E2359, E1012, E1002, E0955, E2311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. The Plan denied your request. The Plan says the clinical value 
and effectiveness of administering Orthovisc every three instead of six months in the setting of osteoarthritis 
have not been demonstrated in the peer-reviewed literature. 
 
The Plan follows Medicare rules. Medicare rules say that it is expected that an injection or course of the 
injections, such as Orthovisc, will not be repeated within six months time. 
 
 
  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 Orthovisc. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Orthovisc. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of osteoarthritis of the knees and has failed conservative non-
pharmacologic therapy and simple analgesics. The Food and Drug Administration has stated that the requested 
drug is indicated for the enrollee's condition. Our reviewer found that the record indicates the enrollee last 
received an injection of the requested device less than six months ago in August 2022. The elements of the 
coverage criteria are not satisfied. Our physician reviewer also found that the requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99214) provided on December 16, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 99214 is not supported in the medical record. Specifically, the claim was billed with 
place of service 10. This was not a valid place of service code at the time the service was provided. Based on 
this information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99214) provided on December 
16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (64479). 
 
You asked the Plan to pre-approve and ESI. You say that the services should be approved. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs should be performed in conjunction with 
conservative treatments. 
 
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 and ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed a course of conservative therapy, such as physical therapy. 
Epidural steroid injections should be performed in conjunction with conservative treatments and the patient 
should be part of an active rehab program, home exercise program, or restoration program. Therefore, the 
reviewer found that the requested ESI is not 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 and ESI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an epidural steroid injection (ESI) (64479).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee deserves the chance to have the 
intensive level of therapy only available in an acute rehabilitation setting, to recover and return home as soon as 
possible and minimize the risk of significant harm. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for an IRF admission. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they meet criteria for admission to an acute 
inpatient rehabilitation facility. The enrollee can receive further services at a lower level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is unstable while walking. The Plan 
denied your request. The Plan says that that the coverage criteria has not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the evaluating therapists show that the enrollee would tolerate and recommend intense therapy. The 
clinical documentation shows that the enrollee would require the management of Parkinson's medications while 
undergoing neurorehabilitation thus IRF criteria has been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says an in-network provider can provide the requested 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office 
services to be provided by an out-of-network provider.