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

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says a repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat ESI. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found the provided documentation 
does not support that the enrollee had 50% pain relief for three months from the initial ESI. Therefore, the 
reviewer found that a repeat ESI 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options/features. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical need for a group 3 power wheelchair with the requested power 
options/features. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the enrollee 
does not require power tilt or recline. The enrollee is not at high risk for skin breakdown, does not use a catheter, have spasticity, or use a ventilator. She has adequate strength to use standards switches to control the 
chair. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options/features.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of chronic kidney disease and iron deficiency anemia. The documentation 
does not support that the enrollee has tried and failed Infed (iron dextran) and Venofer (iron sucrose). The 
documentation does not support that Infed (iron dextran) and Venofer (iron sucrose) 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 Injectafer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sinuva. 
 
You asked the Plan to pre-approve Sinuva. 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 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 Sinuva. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has a diagnosis of ethmoid sinusitis and nasal polyposis. The record does not indicate that the enrollee 
has had sinus surgery. The Food and Drug Administration has not stated that the requested drug is indicated for 
the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not 
satisfied. The requested service cannot be 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 Sinuva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Sinuva.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve repeat ESI. You say that the enrollee tried and failed conservative therapies 
and had relief from their last injection. The Plan denied your request. The Plan says a repeat ESI is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat ESI. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found the provided documentation 
does not support that the enrollee had 50% pain relief for 3 months after the initial injection. Therefore, the 
reviewer found that a repeat ESI 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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62321).
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 cannot take oral bisphosphonates. The Plan 
denied your request. The Plan says 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 Prolia. Our reviewer says that the 
requested drug, Prolia, is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee cannot take oral bisphosphonates. The reviewer found that intravenous 
bisphosphonates may be used. The reviewer found that it is recommended a trial of bisphosphonates be 
completed before Prolia. The reviewer found that the provided documentation does not indicate the enrollee 
has tried and failed the required drug. The reviewer also found that there is no documentation provided 
indicating that the plans required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the requested drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro device. 
 
You asked the Plan to pre-approve the device. You say that this is needed to aid use of the right arm. The Plan 
denied your request. The Plan says there is not enough medical evidence to show this device is helpful. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
patient. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro device.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 99214, 97810, 97814, G0283, 97140 and 20550. We 
decided that the Plan does not have to pay for procedure codes 97010 and 97026.  
 
You asked the Plan to pay for outpatient therapy services (97010, 97026, 99214, 97810, 97814, G0283, 97140 
and 20550) provided on December 31, 2021. You say that these services were medically necessary and are 
supported as billed. The Plan says that code 97026 is not a covered service and the payment for code 97010 is 
always bundled into the payment for another service. 
 
We decided that the Plan has to pay for procedure codes 99214, 97810, 97814, G0283, 97140 and 20550.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided any reason that these codes would be 
denied, nor did the Plan provide a valid reason that the code, or codes, are exempt from the Medicare Managed 
Care Reconsideration appeal process. Therefore, we decided that the Plan has to pay for procedure codes 
99214, 97810, 97814, G0283, 97140 and 20550.  
 
We also decided that the Plan does not have to pay for procedure codes 97010 and 97026. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The rules say that there are no covered 
indications for infrared light therapy. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. In addition, code 97026 is for infrared light therapy, which is 
not covered for any indication. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 97010 and 97026 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 97010 and 97026. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor and transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor and transmitter. You say that you disagree with the 
denial and have submitted clinical documentation. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for coverage under Part B for a non-preferred diabetic supply bought at a pharmacy. 
The enrollee can switch to one of the preferred products. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the requested items have been met. 
Specifically, the documentation submitted does not include any clinical information to verify that the enrollee 
has tried and failed the Plan's preferred brands or that the Plan's preferred brands would be contraindicated for 
her. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 sensor and transmitter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed wing air transport (A0430) and fixed wing air 
mileage (A0435) provided on April 6, 2022.  
You asked the Plan to pay for the fixed wing air transport and mileage. You say that due to the seriousness of 
the enrollee's complaints, as well as the medical interventions needed during transport, transport by air 
ambulance was necessary and reasonable. The Plan denied your request. The Plan says this request is not 
medically necessary because the records do not show that the enrollee had a medical condition that required 
rapid transport or that transportation by ground posed a threat to the enrollee's health or survival. The Plan also 
says that the enrollee was not transported to the nearest appropriate facility. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 fixed wing air transport and mileage. Our 
reviewer says that transportation, via air ambulance, upon discharge, was not medically necessary. Our 
physician reviewer found the enrollee did not require the expertise of trained personnel or the equipment 
available only on an air ambulance to effectuate a safe transport. The enrollee was not being transferred for 
emergency services that were not locally available. Our reviewer found that the enrollee was not transported to 
the closest, appropriate facility. Transportation could have been provided by other means (ground ambulance, 
stretcher van, wheelchair van, private car, taxi) without endangering the enrollees condition. Our physician 
reviewer also found that a prudent layperson would not believe that air-medical transport was required for 
someone who was being discharged from the hospital. 
 
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 fixed wing air transport and mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for the fixed wing air transport (A0430) and fixed wing air mileage 
(A0435) provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM supplies. You say that you need this medical 
equipment as you may even lose your finger due to an infection due to the amount of times you monitor your 
blood sugar. The Plan denied your request. The Plan says you do not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation does not support that you have insulin dependent 
diabetes. The documentation does not support that your diabetes is uncontrolled and therefore, it is not justified 
that you need to test with the glucometer more than once a day. Based on this information, we decided that 
Medicare rules for coverage of the additional supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric wheelchair. 
 
You asked the Plan to pre-approve a wheelchair. The Plan denied your request. The Plan says this is not for use 
in the enrollee's home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an electric wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional accessories for a prosthesis (L5984, L5987). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 accessories. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the appealing provider has not provided any medical records to support that the enrollee has 
vigorous ambulatory activity requiring the additional accessories. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional accessories for a prosthesis (L5984, L5987).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an emergency beeper (A9270). 
 
You asked the Plan to pre-approve the emergency beeper. You say that this device was medically necessary. 
The Plan denied your request. The Plan says this device is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an emergency beeper (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee can move with the aid of a manual mobility device. 
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
presence of sacroiliac pain does not preclude the use of a manual wheelchair. There is no evidence that a 
manual wheelchair is insufficient to meet the enrollee's in-home mobility-associated activities of daily living. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.