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

 
We decided that the Plan does not have to pre-approve a suction pump, home model, portable or stationary, 
electric, any type, for use with external urine management system (K1006). 
 
 
 You asked the Plan to pre-approve a Purewick system. You say that the enrollee is incontinent at night, and it is 
becoming unmanageable. You also say that the enrollee is urinating through multiple pads per night, and she 
needs this item as soon as possible. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for approval of the Purewick system. 
 
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. The records show that submitted clinical documentation indicates 
that the enrollee can postpone urination for two hours. The LCA confirms that the enrollee must have a 
permanent impairment of urination. The use of a urological supply for the treatment of chronic urinary tract 
infection or other bladder condition in the absence of permanent urinary incontinence or retention is non-
covered. Based on this information, we decided that Medicare rules for coverage of a Purewick system have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a suction pump, home model, 
portable or stationary, electric, any type, for use with external urine management system (K1006).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on August 23, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on 
August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D6057). 
 
You asked the Plan to pre-approve the dental services (D6057). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the dental service 
(D6057) is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pre-approve the 
dental service (D6057).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the requested services. You say that the shots will help you get back to 
normal functions. The Plan denied your request. The Plan says there are no plans on using a different approach. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are 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 that in this case, you had an initial response to the first ESI but failed to have a sustained 
response beyond four weeks. There is no documentation that a different approach or medication will be utilized 
for the requested repeat lumbar ESI. Medicare states that if a patient fails to respond well to the initial ESI, a 
repeat ESI after 14 days can be performed, using a different approach, level and/or medication if appropriate, 
with the rationale and medical necessity for the second ESI documented in the medical record. The provider 
has confirmed that the requested repeat ESI will be done by the same approach using the same medication. The 
review has determined that you do not meet the coverage indications 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 an epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care billed with code 99306 for August 
18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99306 is not supported. 
 
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, the CPT Code Manual definition of code 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit. 
 
We find that CPT code 99306 is not supported in the medical record. Specifically, there is no documentation of a comprehensive history. 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 pay for the nursing facility 
care billed with code 99306 for August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulp debridement (D3221), a surgical procedure 
(D3910), and a placement of intra-socket dressing (D7922) for tooth #15 and #29. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for the surgical procedure and 
the placement of intra-socket dressing because they are not covered by the Plan. Also, the enrollee is not 
between the age of 0 to 20 years old; therefore, the pulp debridement is not covered by the 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 surgical procedure and the 
placement of intra-socket dressing are not among those covered under this benefit. Also, the enrollee is not 
between the age of 0 to 20; therefore, the pulp debridement is not covered under the Plan's dental benefit. 
Therefore, we decided that the Plan does not have to pre-approve pulp debridement (D3221), a surgical 
procedure (D3910), and a placement of intra-socket dressing (D7922) for tooth #15 and #29.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee needs this medication for treatment of 
Osteoporosis. The Plan denied your request. The Plan says the records provided support that this enrollee does 
not take enough calcium supplements to safely use Prolia. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable or necessary for the enrollee. Our physician reviewer found based on the provided 
information, and the fact that the enrollee does not take a calcium supplement daily, the enrollee does not meet 
the required intake of 1000 milligrams of calcium daily. There is no evidence that the enrollee is adequately 
supplemented with 1000 milligrams of calcium daily, as required per Medicare criteria. Our reviewer found 
that the review has determined that the requested use of Prolia is not FDA-approved for the enrollees 
diagnosis. Our physician reviewer also found that its use 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intense pulsed light therapy (CPT code 17999). 
 
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 that all services related to the diagnosis and/or treatment of hirsutism or 
hypertrichosis are considered not medically necessary, even if the excessive hair growth is caused by a medical 
disorder. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found based on community standards of care this service 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 service have been met. Therefore, we decided that the Plan has to pre-
approve intense pulsed light therapy (CPT code 17999).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional OT visits. 
 
You asked the Plan to pre-approve six additional OT visits. You say that you do not understand why the 
services would be denied when it is something that you really need. The Plan denied your request. The Plan 
says six additional OT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 six OT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found the record indicates your stroke is stable with no additional neurological 
recovery. OT has had no significant impact on your function and is not necessary for maintenance as you are 
able to do a home exercise program. Continued unique input from a skilled therapist 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 six OT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six additional OT visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac magnetic resonance imaging (MRI) for 
velocity flow mapping. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is clinically appropriate. The Plan denied 
your request. The Plan says there was no unsatisfactory or equivocal echocardiography. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
cardiac MRI for velocity flow mapping is not medically necessary. Our physician reviewer found that the 
documentation does not support the rationale for this imaging study. Guidelines do not support a need for 
cardiac MRI for velocity flow mapping in this setting. As a result, at this time cardiac MRI for velocity flow 
mapping would not be considered medically appropriate and necessary in this enrollee's clinical management. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a cardiac magnetic resonance imaging (MRI) for velocity flow mapping.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental pontic (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 pre-approve a 
dental pontic (D6240).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Blincyto (J9039). 
 
You asked the Plan to pre-approve Blincyto. The Plan denied your request. The Plan says the use of this 
drug/regimen is not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Blinatumomab (J9039) is only covered for the 
conditions listed in the Medicare rules section of this letter. 
 
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 Blincyto. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Blincyto. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of Acute lymphoblastic leukemia not having achieved remission. The record 
indicates that the requested drug is being used as first line therapy. Our reviewer found that the record does not 
indicate that the enrollee has an enumerated condition for which coverage is available. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and 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 Blincyto have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Blincyto (J9039).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on May 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you must continue physical and occupational 
therapy to gain strength in your legs, so you do not continue to fall. You say that you are all black and blue due 
to you falling. The Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialized prosthetic knee (L5828, L5845, L5848, 
L5856, L5920) and ankle-foot system (L5981). 
 
You asked the Plan to pre-approve the requested prosthetic components. You say that it is felt that the 
requested item should be approved. The Plan denied your request. The Plan says the enrollee did not meet all of 
the criteria for the requested prosthetic components. 
 
The Plan follows Medicare rules. Medicare rules say that the medical necessity of certain prosthetic 
components is determined by the enrollee's functional level in most cases.  
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 prosthetic components. 
Our reviewer says that the requested type of knee and ankle-foot system are not shown to be reasonable and 
necessary. Our physician reviewer found the documentation does not reveal primary medical treating 
provider/physician documentation that the enrollee requires a microprocessor knee over a K3 mechanical knee. 
The documentation is not consistent with a K3 ambulator given the enrollee's hip contracture, needing of 
crutches with ambulation. The requested items exceed the patient's medical need as the patient has a prosthetic 
socket with an alignable system and the documentation does not reveal that this item cannot be used with the 
approved socket.  
 
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 prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a specialized prosthetic knee (L5828, L5845, L5848, L5856, L5920) 
and ankle-foot system (L5981).