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

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
 
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show that a cane or walker would not help with limited movement. 
 
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 vehicle. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that you are noted 
to have difficulty ambulating and standing but there is limited clinical documentation or a formal power 
mobility evaluation indicating the need for a power mobility device. There is limited information regarding 
your clinical history, physical examination findings (including motor strength and range of motion), level of mobility and function and ability to safely operate a power mobility device. There is insufficient documentation 
indicating why you cannot use a cane or walker for assistance with mobility or why you cannot propel a 
manual wheelchair for mobility and accomplishing his daily activities. Without this information it cannot be 
determined if the requested power mobility device is appropriate for your condition and 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 vehicle have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0842) and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the covered 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 and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee 
does not have spasticity, does not use a catheter, and is not at high risk for skin breakdown. Since the Group 2 
power wheelchair is not medically necessary, the requested accessories are also not covered. 
 
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 and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 2 power wheelchair (K0842) and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron (J2469). 
 
You asked the Plan to pre-approve Palonosetron. The Plan denied your request. The Plan says based on this 
being a low emetic risk regimen, the use is not found to be reasonable and necessary per compendia. 
 
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 Palonosetron. Our reviewer says that 
Palonosetron is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Palonosetron is not FDA-approved for the enrollees diagnosis. Our reviewer found this is a 
low-risk regimen and there is no documentation of nausea while on treatment. The 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. Our physician reviewer also found that the use is not listed as not 
indicated, not supported or not recommended in any of the compendia. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron (J2469).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
provided on December 18, 2021. 
 
You asked the Plan to pay for the fungal infection PCR panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says PCR testing is not indicated as the following are 
appropriate means to verify fungal infection: direct microscopic examination with potassium hydroxide, fungal 
culture of desquamated subungual material, or fungal stain of a nail clippings fixed in formalin 
 
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 pay for the fungal infection PCR panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the longstanding standard of care for the evaluation of fungus in 
toenails is the performance of both KOH and fungal culture on a toenail specimen. These laboratory tests are 
inexpensive, sensitive, and specific. It is unclear as to why this enrollees toenail required PCR testing as 
compared to KOH and fungal culture. Therefore, the PCR testing of this enrollees toenail was not medically 
reasonable or necessary at this time. 
 
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 fungal infection PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel provided on 
December 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported cast metal crown (D6062). 
 
You asked the Plan to pre-approve the dental services. You say that without the dental implant you are unable 
to eat. You need this authorization to eat properly and improve your overall health. The Plan denied your 
request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 an 
abutment supported cast metal crown (D6062).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on December 24, 
2021, to December 28, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis was coded correctly. The Plan denied your request. The Plan says the clinical evidence does not 
support the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with G93.41, defined as metabolic encephalopathy. 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 pay for the inpatient hospital services at the DRG originally billed. 
Our physician reviewer found that the enrollee presented to the emergency department with worsening 
symptoms associated with dementia including hallucinations, paranoia and memory issues. The worsening 
symptoms were noted for the preceding 6 months. The documentation indicates the enrollee was diagnosed and 
treated for a urinary tract infection and possibly Lewy Body dementia. The documentation does not indicate the 
enrollees mental status was due to a metabolic derangement. The documentation does not consistently and 
completely support the assigned secondary diagnosis code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on December 24, 2021, to December 28, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the durable medical equipment (DME) (E0181, E0260, 
E0310) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve DME. You say that you need the correct mattress to prevent pressure 
wounds. The Plan denied your request. The Plan says these items can be provided in-network. 
 
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 durable medical equipment (DME) (E0181, E0260, E0310) to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the records do not show you have 
failed treatment with CPAP or BIPAP or that the requested NIV will not be used exclusively in CPAP or bi-
level PAP mode. The request is not medically necessary. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) 
mode with auto-titration (AE) which could be provided by a 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 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a history of 
chronic obstructive pulmonary disease (COPD) on home oxygen. She was recently hospitalized with acute 
diverticulitis and developed acute respiratory failure as an inpatient. The arterial blood gas (ABG) on 
admission showed mild carbon dioxide retention with a normal pH. The ABG during respiratory failure was 
consistent with acute-on-chronic hypercarbic respiratory failure. There are no pulmonary function tests to asses the severity of the COPD. Medicare does not cover a home ventilator when used at settings that can be 
provided with bi-level positive airway pressure (BiPAP) and the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on February 14, 
2022, to February 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
coding was submitted in good faith. The Plan denied your request. The Plan says the diagnosis was not 
substantiated as valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with I21.A1, defined as myocardial infarction type 2; myocardial 
infarction secondary to ischemic imbalance. 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 pay for the 
inpatient hospital services at the DRG originally billed. Our physician reviewer found that the enrollee 
presented to the emergency department for confusion and shortness of breath. At the time of presentation, the 
enrollee did not have any chest pain or cardiac symptoms. There were no wall motion deficits consistent with 
ischemia seen on an echocardiogram. The laboratory studies showed an elevated troponin level. The enrollee 
was diagnosed and treated for staphylococcus aureus bacteremia with bilateral lower extremity cellulitis and 
encephalopathy. The cardiologist diagnosed the enrollee with diastolic dysfunction but did not believe her 
dyspnea was due to the heart but a chronic cough and the active infection. The documentation does not indicate 
that the treatment ordered by the treating medical providers supported the diagnosis code. The documentation 
does not consistently and completely support the assigned secondary diagnosis code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on February 14, 2022, to February 25, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
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 you need this type of bed to safely 
transfer and operate the bed. The Plan denied your request. The Plan says this item 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 above the knee prosthetic leg and components to be 
provided by an out-of-network DME provider. 
 
You asked the Plan to pre-approve the out-of-network DME provider services. You say that the doctor referred 
you to this provider because they are willing to go to your home for appointments. You state that you were 
amputated above the knee, and it is very difficult for you to get out of the house until you are able to walk with 
a prosthesis. The Plan denied your request. The Plan says there are in-network DME providers available in 
your area that will come to your home for a fitting. 
 
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 
above the knee prosthetic leg and components to be provided by an out-of-network DME provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service November 2, 
2022 to November 4, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that you were advised this was a covered code. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service November 2, 2022 to November 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) 
(eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging 
guidance (ie, fluoroscopy or CT) (62321). 
 
You asked the Plan to pre-approve the service. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says there are no doctor notes after that to show if the enrollee got better with the 
steroid shot or why a second steroid shot is medically needed. The Plan states there must be doctor notes 
showing the enrollee did or did not improve with the first steroid shot before a second one can be approved. 
The Plan states the last doctor note was from February 16, 2023, before the enrollee had their first steroid shot 
on February 27, 2023. The Plan states they also do not know if the second steroid shot will be at the same 
spinal level or a different level. 
 
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 physician reviewer 
found there were no follow up notes indicating that the enrollee's pain improved after receiving the enrollee's first epidural steroid injection (ESI) on February 27, 2023. According to the coverage criteria, a repeat epidural 
steroid injection is indicated when the medical record documents at least 50% of sustained improvement in 
pain relief and/or improvement in function measured from baseline using SAME scale for at least 3 months.  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 review 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, 
opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) 
(62321).