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

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT (specifically cone beam computed tomography) 
is necessary to be able to visualize the target since this is actually a soft tissue metastasis and not a bone 
metastasis.  If IGRT is denied, the treatment will be inaccurate and will result in inadequate palliation and 
unacceptable toxicity. The Plan denied your request. The Plan says there is no good evidence that IGRT is safe 
or effective for the patient's type of cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found The enrollee is a 71-year-old patient with a diagnosis of bladder (urothelial) cancer metastatic to the skull. The National Comprehensive Cancer Network Guidelines, Version 3.2023, Bladder Cancer, 
05/25/23, PRINCIPLES OF RADIATION MANAGEMENT OF INVASIVE DISEASE does not support the 
use of image guided (specifically cone beam computed tomography) radiation therapy for the treatment of 
bladder (urothelial) cancer metastatic to the skull.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs additional time in the facility. 
You say the enrollee is on two very strong intravenous antibiotics daily and has an infection in their hip. The 
Plan denied your request. The Plan says the enrollee is covered for up to 100 days each benefit period for 
inpatient services in a SNF. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from November 15, 
2022 to August 28, 2023. The Plan has covered 100 days of SNF care.  
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Vacuum socket system (L5781). 
 
You asked the Plan to pre-approve the Vacuum socket system. You say that the item is medically necessary. 
The Plan denied your request. The Plan says that the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the Vacuum socket system. Our 
reviewer says that the requested item is considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records clearly demonstrate the need for the requested item. 
 
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 Vacuum socket system have been met. Therefore, we decided that the Plan 
has to pre-approve the Vacuum socket system (L5781).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 23, 2022, billed with 
evaluation and management (EM) code 99291-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99291-25 is Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes. 
 
We asked our coder 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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that CPT 99291 is a time-based service 
which requires the documentation of the total time that the critical care services were provided. The medical 
records provided does not include sufficient documentation to validate this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 23, 2022, billed with evaluation and 
management (EM) code 99291-25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited, problem focused re-evaluation (D0170) provided 
on March 16, 2023. 
 
You asked the Plan to pay for a limited, problem focused re-evaluation (D0170). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this is not a covered service 
under the members 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 pay for a limited, 
problem focused re-evaluation (D0170) provided on March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine drug testing provided on March 03, 2023. 
 
You asked the Plan to pay for routine drug testing. You say that this is part of a routine narcotics contract, and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for routine drug testing 
provided on March 03, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 90832 provided on January 10, 2023. 
 
You asked the Plan to pay for procedure code 90832. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that there was no documented contact with the 
attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 90832 have been met. Specifically, the record shows that the enrollee was referred 
to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay for 
procedure code 90832 provided on January 10, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation. You say that you are requesting 
reconsideration because the enrollee needs this procedure as soon as possible. The Plan denied your request. 
The Plan says the request is not medically necessary because the records show the enrollee does not have 
documentation showing that he has had failure, contraindications, or intolerance to at least three months of 
medications to treat his urination issues and, the provider describes the enrollee's chronic prostatitis and 
concerns for urethral narrowing/strictures. 
 
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 transurethral waterjet ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not meet criteria for approval of the requested procedure. 
The records do not show that the enrollee has had failure, contraindications, or intolerance to at least three 
months of medications for BPH (e.g., alpha blockers, PDE5 Inhibitors, or finasteride/dutasteride). The records 
also do not show that the enrollee has a maximum urinary flow rate (Qmax) of =15 mL/s (voided volume 
greater than 125 cc) as required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transurethral waterjet ablation of the prostate (0421T).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 You asked the Plan to pre-approve Hyalgan. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Durolane, Euflexxa, Gelsyn-3, Synvisc or Synvisc One is required before 
alternatives can be considered. 
 
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 Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that a therapeutic CGM is medically necessary. 
The Plan denied your request. The Plan says you do not meet Medicare criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a therapeutic CGM. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you are on medications that do not 
typically cause low blood sugars and you are not using insulin. Your blood sugar control is excellent with a1c 
of 6.4 and we are not told of any low blood sugars. We are not told why finger stick monitoring would not 
suffice. Although a CGM might help you, the coverage criteria have not been 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 a therapeutic CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on April 26, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the eye exam. You say that you did not know this exam would not be covered. 
The Plan denied your request. The Plan says this service is not covered when received by an out-of-network 
provider. 
 
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 Plan has a POS benefit, but it does not extend to all covered 
services. The Plan contract also says that out-of-network routine eye examinations are not covered. 
 
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 eye exam provided on April 26, 2023, by an 
OON provider.
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 a power wheelchair. The Plan denied your request. The Plan says based on 
the available documentation, the request does not meet criteria because there are no clinical notes submitted by 
a participating vendor as to why a power wheelchair is now needed, as you currently have a manual 
wheelchair. 
 
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 power wheelchair. Our reviewer says 
that medical necessity for a power wheelchair is not supported in the records. Our physician reviewer found 
you suffered trauma to your left leg and have significant lower leg weakness. You have normal strength in your 
upper extremities and right leg. Our reviewer found that you use a lightweight wheelchair. Our physician 
reviewer also found that you have adequate strength to manage MRADLs with a lightweight wheelchair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the microprocessor knee with positional rotation unit. We 
decided that the Plan does not have to pre-approve adjustable heel height.   
You asked the Plan to pre-approve the microprocessor knee with positional rotation unit (L5828, L5845, 
L5848, L5850, L5856, L5925, K1022) and adjustable heel height (L5990). You say that the items are 
medically necessary. The Plan says that the items are not medically necessary. 
 
We decided that the Plan has to pre-approve the microprocessor knee with positional rotation unit.  
 
The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee 
is covered for beneficiaries whose functional level is 3 or above. Coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 microprocessor knee with positional 
rotation unit. Our reviewer says that this item is medically necessary. Our physician reviewer found the 
physician notes clearly indicate the enrollee is a K3 ambulator.  
 
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 microprocessor knee with positional rotation unit have been met. Therefore, 
we decided that the Plan has to pre-approve the microprocessor knee with positional rotation unit.  
 
We also decided that the Plan does not have to pre-approve adjustable heel height. 
 
The Plan follows Medicare rules. Medicare rules say that a user-adjustable heel height feature (L5990) will be 
denied as not reasonable and necessary. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of adjustable heel height have not been met. Therefore, we decided that the Plan does not have to pre-
approve adjustable heel height. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent before your hospitalization 
and you want to return to being independent.  The Plan denied your request. The Plan says the IRF services 
requested do not meet the requirements for approval.  
 
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 that your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (POV) 
(K0800). 
 
You asked the Plan to pre-approve a group 1 standard POV. You say that a walker and manual chair meets 
needs of daily activities and living. The Plan denied your request. The Plan says the requested service is not 
covered by Medicare or the health plan. 
 
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 1 standard POV. Our reviewer 
says that you do not meet the criteria for coverage. Our physician reviewer found you are able to walk with a 
walker. Our reviewer also found that you do not require a POV to perform MRADLs. 
 
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 1 standard POV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 1 standard power operated vehicle (POV) (K0800).