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

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823) and 
retractable or removable mounting hardware for joystick (E1028). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and retractable or removable mounting 
hardware for joystick. You say that the doctor's notes state that the enrollee is unable to walk or use a single 
point cane, walker to safely access their home environment. You also say that you would like this request to be 
reviewed. The Plan denied your request. The Plan says this request does not meet criteria for coverage. The 
Plan also says that the enrollee does not need a power wheelchair to be mobile in their home. 
 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 a group 2 standard power wheelchair 
and retractable or removable mounting hardware for joystick. Our reviewer says that the enrollee does not meet 
the coverage criteria. Our physician reviewer found the enrollee has cervical stenosis. The enrollee becomes 
fatigued at times and falls. Our reviewer found that the enrollee is able to self-propel a wheelchair to the store, 
but they do develop pain. Our physician reviewer also found that the enrollee is able to use a manual 
wheelchair to perform MRADLs in the home. 
 
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 group 2 standard power wheelchair and retractable or removable mounting 
hardware for joystick have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 2 standard power wheelchair (K0823) and retractable or removable mounting hardware for joystick 
(E1028).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (27691, 20680) provided on March 17, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (27691, 20680) is included in the 
global surgery payment for the procedure (28120) provided on January 13, 2022, which has a 90-day 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 the services (27691, 20680) provided on 
March 17, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Gamunex (J1561). 
 
You asked the Plan to pre-approve Gamunex. You say that Gamunex is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says that the requested drug has been prescribed for an off-label, not 
medically accepted use. 
 
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 Gamunex. Our reviewer says that 
treatment with Gamunex is medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has a diagnosis of antibody positive Myasthenia Gravis. The FDA has not stated that the requested 
drug is indicated for the enrollee's condition. However, the Medicare-approved drug compendia do contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex have been met. Therefore, we decided that the Plan has to pre-
approve treatment with Gamunex (J1561).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care at the inpatient level. 
 
You asked the Plan to pre-approve a continuation of care at the inpatient level. You say that the enrollee 
requires a continued hospital stay due to acute renal failure, 3rd spacing, and extensive anasarca. You say that 
the enrollee is hypotensive and cannot be given diuretics. You say that the enrollee has had 2 falls and is not 
able to ambulate, therefore is not cleared for physical therapy. You say that you expect the patient to require 
hospitalization for 1 more week.  The Plan denied your request. The Plan says the medical necessity criteria 
have not been met because the enrollee's needs can be met at a lower level of care.  
 
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 a continuation of care at the inpatient 
level. Our reviewer says that a continuation of care at the inpatient level is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presented to clinic on July 11, 2023, with 
tachycardia, hypotension, and concerns for sepsis. He complained of fatigue and weakness in bilateral legs. 
Reports falling 2 times, did not lose consciousness, did not hit head, and did not sustain injury. The enrollee's 
past medical history includes diffuse large B-cell lymphoma, germinal subtype. The enrollee completed 2 
cycles of mini RCHOP-chemotherapy for germinal Diffuse large B-cell lymphoma (DLBCL.) The enrollee had 
partial response and many of his lymph nodes decreased in size; however, a positron emission tomography 
(PET) scan was completed on July 5, 2023. He was admitted to Roswell Park Cancer Institute on July 11, 2023. 
He was found to have bacteremia. Member found to be positive for Listeria, and the inpatient doctor 
recommended intravenous (IV) ampicillin Q4H for 4 weeks. He underwent a 2D Echo while inpatient, showing 
no evidence of infectious endocarditis. The enrollee has stable persistent clot in the right lower extremity and 
stable lymphadenopathy in the abdomen and pelvis on computed tomography (CT) done on July 11, 2023. 
Currently, the enrollee is stable for discharge.  There is no medical indication for continued inpatient level of 
care services. 
 
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 continuation of care at the inpatient level have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care at the inpatient level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service February 15, 
2023. 
 You asked the Plan to pay for procedure code 99152. The Plan denied your request. The Plan says payment for 
code 99152 is bundled into payment for code 45385. 
 
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 99152 
is a column II code to column I code 45385. 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 99152 billed for date of 
service February 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for pelvic fracture after a fall. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75710 billed for date of service February 17, 
2023. 
 You asked the Plan to pay for procedure code 75710. The Plan denied your request. The Plan says payment for 
code 75710 is bundled into payment for code 37225. 
 
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 75710 
is a column II code to column I code 37225. 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 75710 billed for date of service February 17, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left C3 - C5 Medial Branch Block (MBB). 
 
You asked the Plan to pre-approve the MBB. You say that it may be in the enrollee's best interest to start with 
the MBB/RFA (radiofrequency ablation) to focus on the facet pain source first. The Plan denied your request. 
The Plan says that MBB is not covered under Medicare guidelines, and not medically necessary based on the 
plan language, Medicare guidelines, and the clinical information reviewed. The Plan follows Medicare rules. Medicare rules say that MBB may be covered under certain circumstances. 
 
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 MBB. Our reviewer says that the 
enrollee does not meet the coverage indications for this procedure. Our physician reviewer found that the 
enrollee has radicular pain to the left arm with numbness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBB have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a left C3 - C5 Medial Branch Block (MBB).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve the mechanism. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are 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 the mechanism. Our reviewer says that 
the requested mechanism is not medically reasonable or necessary. Our physician reviewer found that the enrollee uses a wheelchair. The enrollee's ability to rise from a chair is limited. However, the enrollee is not 
completely unable. Once up, the enrollee is non-ambulatory. 
 
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 mechanism have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the procedure is necessary. The Plan 
denied your request. The Plan says that the request does not meet medical necessity criteria. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered under certain 
circumstances. 
 
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 facet joint injections. Our reviewer says 
that the requested procedure is not medically reasonable or necessary according to the coverage criteria 
established in the above LCD. Our physician reviewer found you have low back pain with radicular pain to 
your right lower extremity. In addition, there was not a consistent positive response of at least 80% relief of 
primary (index) pain (with the duration of relief being consistent with the agent used). The review has 
determined that you do not meet the criteria for the requested procedure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and accessory 
(E0667) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that no other 
supplier can provider the unique equipment needed. The Plan denied your request. The Plan says this is 
available 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 provider at issue in this case is not a network provider with the Plan. 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 pneumatic compression device and accessory. Our reviewer says that 
there is insufficient support in the submitted records for an out-of-network provider to provide the requested 
items. Our physician reviewer found while the requested out-of-network pump is unique in that it has a focal 
therapy option to concentrate on a specific area, the provided records do not describe the patient having tried 
and failed a regular compression pump without this unique feature. There is nothing clinically unique that 
would suggest likely failure of a regular pump from an in-network provider.  
 
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 pneumatic compression device and accessory have not been met.  
 
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 a pneumatic compression device and accessory. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and 
accessory (E0667) 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 pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that the enrollee's pain has limited the 
enrollee's ability to walk. The Plan denied your request. The Plan says that it 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 genicular nerve ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested radiofrequency ablation 
of the genicular nerve for chronic knee pain 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to a LTACH is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and does not require transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute on chronic renal failure. The record indicates 
that the enrollee has ongoing acute medical issues and still requires acute care services. The enrollee continues 
to receive acute care services, and these have not been denied. The medical record does not indicate that the 
enrollee requires services that he is not currently receiving but that would be available at the LTACH 
facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided on January 16, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this testing is not 
covered when provided OON. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the drug testing (G0483) provided on January 16, 
2023, by an out-of-network (OON) provider.