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

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0861, E0960, E2300, E2359, 
E1007, E2311, E1012, E0955, E1028, E2377, E2313, E2609, E2617, E0950, E1028). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the chair is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 power wheelchair. Our reviewer 
says that the power wheelchair is not medically necessary. Our physician reviewer found the records indicate 
that the enrollee cannot effectively and safely control the chair herself. The record shows the patient's right 
upper limb as non-functional and shows limited use of the left upper extremity.  
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (K0861, E0960, E2300, E2359, E1007, E2311, E1012, 
E0955, E1028, E2377, E2313, E2609, E2617, E0950, E1028).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis tablets. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says Eliquis tablets are not covered under the 
enrollee's Medicare Part B benefit. 
 
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 Eliquis tablets.  
 
Benefits for Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the step therapy requirements were not 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 Gelsyn-3. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has not trialed one preferred 
viscosupplemental treatment such as Orthovisc or Supartz FX and the documentation does not outline 
contraindications or reasons one of these medications were not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 20, 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 this service is included in the global package. 
 
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 49083 is "Abdominal paracentesis (diagnostic or 
therapeutic); with imaging guidance." 
 
We find that CPT code 49083 is not supported in the medical record. Specifically, this is a minor procedure 
that has a global surgery period of ten days. The surgery was on May 19, 2021, so CPT 49083 is within the 
global period. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for surgical services provided to the 
enrollee on May 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Novolog. 
 
You asked the Plan to pre-approve a tier exception for Novolog. You say that you cannot afford this, and 
authorization is needed. The Plan denied your request. The Plan says there is not a lower tier or lower cost 
option available. Therefore, this drug is not eligible for a Tier Exception. 
 
The Plan must follow Medicare rules. Medicare rules say that each Part D plan sponsor that provides 
prescription drug benefits for Part D drugs and manages this benefit through the use of a tiered formulary must 
establish and maintain reasonable and complete exceptions procedures subject to CMS approval for this type 
of coverage determination.   
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Tier Exception for Novolog have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tier exception for Novolog.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 17, 
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 provider did not bill as required by Medicare coding regulations. 
 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 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, 
the documentation does not support that it is medically reasonable and necessary to continue skilled services on 
a "daily basis" on an inpatient basis, in a skilled nursing facility setting. Medicare coverage criteria are not 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on 
October 22, 2021. 
 
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you were told that 
you would only owe a $10 copayment and now you are receiving a $240 charge. The Plan denied your request. 
The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for diagnostic radiology services that are not ultrasounds.  
 
 You have been asked to pay a $250 copayment for myocardial perfusion imaging. Myocardial perfusion 
imaging falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for myocardial perfusion imaging provided on October 22, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, 
the documentation does not support that it is medically reasonable and necessary to provide these skilled 
nursing or skilled therapy services (or a combination of these services) on a "daily basis" on an inpatient basis, 
in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inflectra (Q5103). 
 
You asked the Plan to pre-approve Inflectra. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not approved by the FDA for the enrollee's diagnosis. 
 
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 Inflectra. Our reviewer says that the 
requested drug, Inflectra, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
reviewer found that the Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested drug is 
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 Inflectra have not been met. Specifically, the file does not indicate that the FDA 
has approved the requested drug for the enrollee's condition. Therefore, we decided that the Plan does not have 
to pre-approve Inflectra (Q5103).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Allograft, morselized, or placement of osteopromotive 
material, for spine surgery only (20930) provided on August 22, 2021. 
 
You asked the Plan to pay for code 20930. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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 looked at the file and Medicare rules. Code 20930 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the Allograft, morselized, or placement of osteopromotive material, for 
spine surgery only (20930) provided on August 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found the imaging does not show any lesions that would cause radiculopathy.  There is no 
documentation of Electromyography (EMG)/nerve conduction velocity (NCV) studies that support the 
diagnosis of radiculopathy.  The request is 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (J0172). 
 
You asked the Plan to pre-approve Aduhelm. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says it has not been established that all the enrollee's 
symptoms can be attributed to early Alzheimer's Disease. The Plan also says that the requested drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aduhelm. Our reviewer says that the 
requested drug, Aduhelm, is not medically necessary. Our physician reviewer found there is insufficient 
documentation to demonstrate that Aduhelm is medically reasonable and necessary for the enrollee in this case. 
The enrollee's Beta-amyloid 42/40 ratio is greater than 0.058. The reviewer found that ratios less than 0.058 
indicate a higher likelihood of a patient having a clinical diagnosis of Alzheimer's disease. The reviewer also 
found that based on the provided documentation the requested drug is not safe and effective 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 Aduhelm have not been met. Specifically, the file does not indicate that the 
enrollee has a clinical diagnosis of Alzheimers disease. Therefore, we decided that the Plan does not have to 
pre-approve Aduhelm (J0172).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablet. 
 
You asked the Plan to pre-approve ondansetron. You say that this drug has been prescribed for the enrollee's 
medication. You say that the enrollee has been unable to have their gallstone removed. You also say that the 
enrollee needs the requested drug. The Plan denied your request. The Plan says the requested drug is 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 ondansetron tablet.  
 Benefits for ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on July 27, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the codes are 
not supported in the documentation. 
 
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 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm.  
 
The CPT Code Manual definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each 
additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure).  
 The CPT Code Manual definition of code 15004 is surgical preparation or creation of recipient site by excision 
of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, 
face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% 
of body area of infants and children. 
 
We find that the CPT codes at issue are not supported in the medical record. There are more comprehensive 
codes to describe the layered closure procedure provided to the enrollee. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the surgery services provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on 
March 4, 2021. 
 
You asked the Plan to pay for the services provided. You say that the billed codes are payable. The Plan denied 
your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that pedicle testing, a lower electromyography, and a free-running needle electromyography 
were provided to the enrollee. We find that CPT codes billed do not accurately describe the neuromonitoring 
services provided to the enrollee. There are more comprehensive codes available to illustrate the services at 
issue in this case.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services 
provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Euflexxa.  
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 Euflexxa. Our reviewer says that the 
enrollee does not meet criteria for the requested Euflexxa. Our physician reviewer found viscosupplementation 
may be considered medically necessary "if the clinical diagnosis is supported by radiologic evidence of 
osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral 
cysts." The enrollee has not met the criteria for treatment with this drug.  The review of this case has 
determined that the medical records provided do 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary rehabilitation (rehab) services. 
 
You asked the Plan to pre-approve pulmonary rehab. You say that you need these services. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary PR programs 
for those with moderate to very severe COPD. There must be a referral from the doctor treating the disease.  
 The services must be provided in a doctors office or an outpatient hospital setting. The PR program must 
include specific components. Benefits are limited to a maximum of 36 visits, with an additional 36 visits if 
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 pulmonary rehab. Our reviewer says 
that pulmonary rehab is not medically necessary. Our physician reviewer found the enrollee is experiencing 
cough and dyspnea following coronavirus pneumonia. The provided documentation indicates that a normal 
pulmonary function test. The reviewer also found that the enrollee does not have a diagnosis of COPD. 
Therefore, the reviewer found that the requested pulmonary rehab is not medically necessary because Medicare 
coverage criteria are not 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 pulmonary rehab have not been met. Specifically, the file shows that the 
enrollee does not have a diagnosis of COPD. Therefore, we decided that the Plan does not have to pre-approve 
pulmonary rehabilitation (rehab) services.