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

 
We decided that the Plan does not have to pre-approve the office or other outpatient visit for the evaluation and 
management of a new patient (CPT code(s): 99203 and 99213) to be provided by a chiropractor. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve the office 
or other outpatient visit for the evaluation and management of a new patient (CPT code(s): 99203 and 99213) 
to be provided by a chiropractor.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 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 Gel-One. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that there 
is no documentation of first-line drug injection such as Synvisc or Orthovisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gel-One (J7326).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 5, 
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 the codes were not billed with an allowed modifier. 
 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 imaging services provided to the enrollee on November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee walker. 
 
You asked the Plan to pre-approve a knee walker. You say that this is necessary because you had surgery and 
cannot put pressure on your leg. The Plan denied your request. The Plan says that this is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitutes (E0118). 
 
We looked at the file and Medicare rules. The DME MAC, the contractor responsible for coverage of medical 
equipment in the State of Florida has decided that the knee walker coded as E0118 is not medically reasonable 
and necessary. Based on this information, we decided that Medicare rules for coverage of a knee walker have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a knee walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor for the enrollee. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that this is medically necessary. 
The Plan denied your request. The Plan says that the enrollee does meet criteria for coverage. 
 
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 
Freestyle Libre CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor (CGM) sensor for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Rybrevant (J9061, 96413, 96415). 
 
You asked the Plan to pre-approve Rybrevant. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested drug has been prescribed for an off-label and unsupported use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Rybrevant. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. No literature from Medicare-approved cancer journals were submitted for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rybrevant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Rybrevant (J9061, 96413, 96415).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF criteria and will benefit from 
IRF care. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been 
met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried conservative 
treatments with poor results. The Plan denied your request. The Plan says coverage guidelines have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain 
medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found there is documentation that the enrollee's pain causes a functional deficit measured on a pain or 
disability scale.  However, there is no documentation of moderate to severe chronic neck pain. There is lack of 
documentation for a minimum of 3 months with documented failure to respond to noninvasive conservative 
management.  Per coverage criteria, repeat RFA as the same site is considered medically reasonable and 
necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six months 
or at least 50% consistent improvement in the ability to perform previously painful movements as compared to 
the baseline measurement. Based on the rules and records provided, the enrollee does not meet the coverage 
criteria for the requested procedure. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Emerg Auto-Emersiontherapy and Umano Ook 
Snow total electric hospital bed. 
 
You asked the Plan to pre-approve the DME. You say that you are requesting approval for the DME. The Plan 
denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. A total electric hospital bed is not 
medically necessary because the ability to change the height is to make it easier for your caregiver. Total 
electric beds will be denied as not reasonable and necessary. Additional expenses for "deluxe" features, or 
items that are rented or purchased for added convenience, do not meet the reasonableness test. Therefore, we 
decided that the Plan does not have to pre-approve an Emerg Auto-Emersiontherapy and Umano Ook Snow 
total electric hospital bed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health counseling to be provided by provider not 
certified by Medicare. 
 
You asked the Plan to pre-approve the services. You say that this provider is still credentialed to see Medicare 
members and is actively working with Medicare to become certified. The Plan denied your request. The Plan 
says this provider is currently not certified by Medicare, but if certification is obtained then this care can be 
approved at that time. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. This provider is currently not 
certified by Medicare. Therefore, we decided that the Plan does not have to pre-approve mental health 
counseling to be provided by provider not certified by Medicare.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds (12011) provided on 
July 24, 2021. 
  You asked the Plan to pay for the simple repair of superficial wounds (12011). You say that the doctor was 
called to consult the patient for a reconstruction of the right orbital floor fracture and repair the eyelid 
laceration. You say that the patient was admitted to the emergency room with no opportunity to choose an in-
network provider and the claim should be processed at the in-network benefit level. The Plan denied your 
request. The Plan says the denial for procedure code 99283 has been overturned. The Plan also says that 
procedure code 12011 remains denied as an appropriate modifier was not billed with the code edit. 
 
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 12011 
is a column II code to column I code 21390. 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 the simple repair of superficial wounds (12011) provided on July 
24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty wheeled walker (E0149). 
 
You asked the Plan to pre-approve a heavy-duty wheeled walker. You say that you do no feel safe on your 
current walker. The Plan denied your request. The Plan says rules for coverage for the requested item have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty walker (E0148, E0149) is covered 
for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty wheeled walker have not been met. Specifically, the available medical records 
indicate that your weight is less than 300 pounds. Therefore, we decided that the Plan does not have to pre-
approve a heavy-duty wheeled walker (E0149).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinalysis services provided to the enrollee on October 27, 
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 the denied code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for urinalysis services provided to the enrollee on October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Insertion of pacemaker pulse generator only (33225) 
and Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-
defibrillator pulse generator (33264). 
 
You asked the Plan to pre-approve these services. You say that that your current defibrillator is basically 
useless. The Plan denied your request. The Plan says that your current device must be at the end of its battery 
life, or the device or a lead is not working as it should. 
 
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 requested services are not considered medically reasonable and necessary in this case. Your ECG shows a 
QRS duration of 114ms. As such, you do not meet guideline criteria for biventricular pacing. In summary, there 
is insufficient documentation to support the medical necessity for removal of the dual-chamber defibrillator and 
replacement with a bi-ventricular defibrillator (CRT-D). Our physician reviewer found that your condition does 
not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Insertion of pacemaker pulse generator only (33225) and Removal of pacing cardioverter-
defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator (33264).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (CPT code(s): E0667 
and E0652) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network DME. You say that this company would teach the 
enrollee how to use this equipment. The Plan denied your request. The Plan says there are in-network provides 
that can provide the services. The Plan states the providers also said they are able to send representatives to the 
enrollee's home to assist with set up and use instruction. 
 
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 pneumatic compression device (CPT code(s): E0667 and E0652) to be provided by an out-of-network 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Emerg auto-emersion therapy system with deluxe 
features (E1399). 
 
You asked the Plan to pre-approve the Emerg auto-emersion therapy system with deluxe features. You say that 
the item is medically necessary. The Plan denied your request. The Plan says this item has deluxe features that 
are not medical in nature and equipment which basically serves comfort or convenience functions does not 
constitute medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the Emerg auto-emersion therapy system with deluxe 
features (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed.. You say that this would allow you to move on 
your own. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve the sleeve. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is denied as 
noncovered, since it does not meet the definition of a prosthesis. 
 
The requested sleeve Based on this information, we decided that Medicare rules for coverage of the sleeve have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast implant surgery. 
 
You asked the Plan to pre-approve the surgery. You say that you have major depression. The Plan denied your 
request. The Plan says this is being done for cosmetic procedures. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
The case file indicates that this request is based on cosmetic and aesthetic needs. Based on this information, we 
decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve breast implant surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home laboratory services. 
 
You asked the Plan to pre-approve home laboratory services. You say that you are in pain and unable to walk 
more than 10 steps. The Plan denied your request. The Plan says the medical records do not support that you 
are homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home laboratory services.