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

 
We decided that the Plan does not have to pre-approve a K3 knee (L5822, L5845, L5850) and a protective 
cover (K5964). 
 
You asked the Plan to pre-approve the K3 knee and protective cover. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says the requested K3 knee and protective cover 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee 
(L5822) is covered for beneficiaries whose functional level is 3 or above. The rules also say that protective 
covers are not for cosmetic or convenience reasons, or for everyday usage in a typical environment. 
 
 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 K3 knee and protective cover. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that the provided 
documentation does not show the enrollee is ambulating at a K3 level. The enrollee is reported to have an 
unstable gait and uses a walker. The medical visit note dated February 23, 2023, reports the enrollee is a K2 
ambulator. The provided medical records do not document that the enrollee will be exposed to such an 
unusually harsh and difficult environment that the standard prosthetic cover would be inadequate for his needs. 
 
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 K3 knee and protective cover have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a K3 knee (L5822, L5845, L5850) and a protective cover (K5964).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oxygen concentrator (E1390) and a portable gaseous oxygen 
system (E0431). 
 
You asked the Plan to pre-approve an oxygen concentrator and a portable gaseous oxygen system. You say that 
you disagree with the denial and request reconsideration. The Plan denied your request. The Plan says that the 
rental period has capped, and the equipment is now purchased/owned. The enrollee has used thirty-six months 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that at any time after the end of the 5-year reasonable 
useful lifetime for oxygen equipment, the beneficiary may elect to receive new equipment, thus beginning a 
new 36-month rental period.  
 
We looked at the file and Medicare rules. Medicare rules say that the RUL for oxygen equipment is five years. 
It starts on the initial date of service and runs for five years from that date. The records show the enrollee 
received an oxygen concentrator and a portable oxygen system on March 5, 2016. The enrollee used thirty-six 
months of this service as of March 4, 2019. There is no further payment for oxygen equipment during the five-
year RUL of the equipment after thirty-six rental payments have been made. The records also show that as of 
March 4, 2021, the enrollee reached the RUL, therefore, the enrollee may elect to receive new equipment and 
begin a new thirty-six-month rental period. Based on this information, we decided that Medicare rules for 
coverage of an oxygen concentrator and a portable gaseous oxygen system have been met. Therefore, we 
decided that the Plan has to pre-approve an oxygen concentrator (E1390) and a portable gaseous oxygen 
system (E0431).  
 
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 a percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve an injection. You say that the procedure is medically necessary. The Plan 
denied your request. The Plan says these types of injections are unproven and 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 an injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain. He has tried physical therapy, chiropractic, TENS, 
massage, heat, ice, bracing and exercise. The enrollee has tried NSAIDs and opiates. Imaging shows multi-
level degenerative disc disease and spinal stenosis. This is an experimental procedure. Evidence is lacking. 
There is insufficient high-quality evidence to support percutaneous injection of allogeneic cellular/tissue-based 
products for treating discogenic pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral 
disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home, or custodial care visit provided on 
November 9, 2022. 
 
You asked the Plan to pay for the domiciliary, rest home, or custodial care visit. You say that the services were 
medically necessary. The Plan denied your request. The Plan says with the information we have, we cannot 
determine how the member came to the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the domiciliary, rest home, or custodial 
care visit have been met. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home, 
or custodial care visit provided on November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller for an approved power 
wheelchair with related electronic connections and harness, as well as a vertical adjustment assembly for the 
controller. 
 
You asked the Plan to pre-approve the expandable controller and related accessories. You say that it is felt that 
this should be approved. The Plan denied your request. The Plan says these items 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 the expandable controller and related 
accessories. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee has cerebral palsy. An expandable controller is 
requested to allow control of the power tilt and power-elevating leg rests from the main control. However, the enrollee has adequate upper body strength to manage standard power drive switches on a power wheelchair. As 
such, the expandable controller exceeds the medical need. 
 
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 expandable controller and related accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller for an approved power 
wheelchair with related electronic connections and harness, as well as a vertical adjustment assembly for the 
controller.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 17, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 21, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronic Acid Injections to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Hyaluronic Acid Injections. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there are in-network providers that can perform 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 
Hyaluronic Acid Injections 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 pay for physician's services for an influenza virus vaccine provided 
on November 1, 2022. 
 
You asked the Plan to pay for the physician's services for an influenza virus vaccine. The Plan denied your 
request. The Plan says you received the services from a provider who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services for an influenza virus vaccine provided on November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebroplasty and vertebral 
augmentation procedure. 
 
You asked the Plan to pre-approve a percutaneous vertebroplasty and vertebral augmentation procedure. You 
say that the service is medically necessary. The Plan denied your request. The Plan says the service is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say a percutaneous vertebroplasty and vertebral augmentation 
procedure is covered when the criteria listed in the Medicare Rules section is 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 a percutaneous vertebroplasty and 
vertebral augmentation procedure. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the enrollee does not have an acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic 
VCF. 
 
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 percutaneous vertebroplasty and vertebral augmentation procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous vertebroplasty and 
vertebral augmentation procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use in targeted tidal volume-volume assured pressure support (TTV-VAPS) 
mode with auto-titration (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device 
with average volume assured pressure support (AVAPS) and a back-up rate.  As stated in the Local Coverage 
Determination (L33800): "Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that this benefit should be covered. The Plan denied your 
request. The Plan says you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. 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 Injectafer. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug, Injectafer. There is 
no indication that the enrollee has tried and failed the required drugs. Based on the medical records provided 
and the Medicare-approved major drug compendia, there is no indication that the Plan's required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Injectafer (J1439).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic radiology services provided on  
September 16, 2022. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
Medicare is responsible for payment for these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for diagnostic radiology services provided on  
September 16, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found based on the medical records provided there is documentation that you require the 
services on an inpatient basis in a skilled nursing facility setting due to your level of functional decline 
compared to your recent baseline. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as you no longer need the service and proper notice has been issued, or the 100-day 
Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility 
(SNF) care.  
 
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.