Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99284 billed for date of service July 16, 2023. 
 
You asked the Plan to pay for code 99284. You say that the provided service was significant and separately 
identifiable. The Plan denied your request. The Plan says the service at issue was not billed with the required 
modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 
G0168 provided on July 16, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for code 99284 billed for date of service 
July 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorper. 
 
You asked the Plan to pre-approve the medication. You say that this medication is necessary for the enrollee. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although prochlorper is among the drugs that may be covered by Medicare Part B, this 
request does not fall within Part B coverage because the prochloper will not be used as a full therapeutic 
replacement for intravenous (IV) anti-emetic therapy that would have otherwise been administered at the time 
of the cancer chemotherapy treatment, or that is will be administered within 2 hours of the chemotherapy for a 
period not to exceed 48 hours from that time. Therefore, we decided that the Plan does not have to pre-approve 
prochlorper.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT procedure. 
 
You asked the Plan to pre-approve the SPRINT procedure. You say that the SPRINT procedure is 
medically necessary. The Plan denied your request. The Plan says the SPRINT procedure 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 SPRINT procedure. Our reviewer 
says that the requested SPRINT procedure is not considered medically reasonable and necessary. Our 
physician reviewer found the SPRINT PNS device is experimental for chronic pain treatment. 
 
 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 SPRINT procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial mandibular denture (D5214) provided on May 25, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this denture. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 30, 2021. 
Therefore, we decided that the Plan does not have to pay for a partial mandibular denture (D5214) provided on 
May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service August 14, 
2023. 
 You asked the Plan to pay for procedure code 81456. The Plan denied your request. The Plan says payment for 
code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455. 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 81456 billed for date of 
service August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 heavy duty power scooter (E1399). 
 
You asked the Plan to pre-approve a power scooter. You say that you have a scooter but cannot go more than 2 
blocks and cannot go shopping without the scooter. You are prone to falling and is prohibited from walking on 
doctor's order.  The Plan denied your request. The Plan says the enrollee does not meet the weight requirement 
of the requested POV. There must be an evaluation of your ability to walk and do activities in the home and the 
scooter cannot be for outside use.  
 
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 scooter. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation available for review does not support that the enrollee requires a power 
mobility device to accomplish mobility related self-care tasks in the home. There is no indication they are 
unable to use an alternative assistive device. 
 
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 scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 heavy duty power scooter (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman G5 MIS Fusion Plate. 
 
You asked the Plan to pre-approve the Minuteman G5 MIS Fusion Plate. You say that the Minuteman G5 MIS 
Fusion Plate is medically necessary. The Plan denied your request. The Plan says the requested Minuteman G5 
MIS Fusion Plate 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 Minuteman G5 MIS Fusion Plate. 
Our reviewer says that the requested Minuteman G5 MIS Fusion Plate is not considered medically reasonable 
and necessary. Our physician reviewer found that the Minuteman G5 MIS Fusion Plate is experimental. 
 
 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 Minuteman G5 MIS Fusion Plate have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Minuteman G5 MIS Fusion Plate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 13, 2023. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this is medically reasonable and 
necessary for the enrollee. The Plan denied your request. The Plan says this is experimental and therefore is not 
covered. 
 
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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer 
found that the requested CardioMEMS device 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extra in-home support services. 
 
You asked the Plan to pre-approve the extra in-home support services. You say that you are unable to perform 
home tasks on your own due to medical issues. The Plan denied your request. The Plan says the benefit has 
been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that that custodial care is not covered. Custodial care 
is personal care for a person who does not need ongoing care from trained medical or paramedical staff. 
Custodial care serves to help with the activities of daily living. This means the care includes help in walking, 
getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of 
medicine that usually can be self-administered are also custodial care services. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 16, Section 110.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the extra in-home support services have not been met. Specifically, the benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve the extra in-home support services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee's pain is disabling, affects 
his quality of life on a daily basis. The appellant says the enrollee has failed non-operative treatment, the 
Intracept procedure is the only solution. The Plan denied your request. The Plan says the Intracept procedure is 
not medically necessary. The Plan says the imaging does not show Type 1 or Type 2 Modic changes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We reviewed the local coverage determination (LCD) cited by the Plan was found 
that it is not applicable to the state where the requested service will be performed. 
 
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 Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease or stenosis. This means that the cause of pain is not clear.  
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve replacement Group 3 power wheelchair, multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds K0861.  
 
You asked the Plan to pre-approve the replacement wheelchair. You say that please review the attached 
medical documentation to support the need of the custom medical equipment being requested  The Plan denied 
your request. The Plan says that the enrollee does not have medical need for multiple power options included 
with K0861 group 3 power wheelchair.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 replacement wheelchair. Our 
reviewer says that the requested items/services is considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a medical history of Parkinson's Disease. Other conditions are 
notable for atrial fibrillation, stroke, heart failure and degenerative disease of the lumbar spine. The enrollee 
currently uses a Group 3 power wheelchair with power tilt and recline for mobility and performing daily 
activities. The enrollee is functionally non-ambulatory and cannot use a cane or walker for mobility. They 
cannot functionally propel a manual wheelchair due to upper extremity weakness and dystonia. The enrollee 
requires a power wheelchair for mobility and accomplishing their daily activities. The enrollee requires a new 
Group 3 power wheelchair because the current chair was damaged in an accident in which it was struck by a 
motor vehicle. The enrollee is unable to independently perform pressure relief and requires power tilt and recline and he requires power elevating leg rests for positioning and his lower extremity dystonia. The power 
seat elevator will allow for increased independence with transfers and daily activities. Therefore, the group 3 
power wheelchair with power tilt & recline, power elevating leg rests and power seat elevator is 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 replacement wheelchair have been met. Therefore, we decided that the Plan 
has to pre-approve replacement Group 3 power wheelchair, multiple power option, sling/solid seat/back, 
patient weight capacity up to and including 300 pounds K0861.   
 
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 group 3 standard power wheelchair with single power 
option and accessories (E0951, E0955, E1002, E1028, E2310, E2363, E2615, E2624, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that your current chair is 5 
years old, has a worn-out seat, worn out tires, and multiple other issues. You also say that you are a 
quadriplegic and really need this chair to function. The Plan denied your request. The Plan says you do not 
have a medical need for a single power option included with a group 3 power wheelchair. The Plan also says 
the electronic connection is not medically needed as there is no need to control one power option through the 
joystick. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have a neurologic disorder with functional deficits. The 
documentation does not indicate that you have any pressure injuries or require intermittent catheterization of 
the bladder or have spasticity that would necessitate power tilt or recline. Although your condition may meet 
criteria for a PWC, the criteria for this specifically requested power wheelchair are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power option and 
accessories (E0951, E0955, E1002, E1028, E2310, E2363, E2615, E2624, K0040).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair (PWC) with 
multiple power options (K0861) and additional items and accessories (E0955, E1007, E1012, E1028, E2300, 
E2311, E2313, E2361, E2377, E2607, and E2620). 
 
You asked the Plan to pre-approve the Group 3 PWC with multiple power options and the related items. You 
say that you would like the addendum to be reviewed for more medical justification for the denied recline 
feature. The Plan denied your request. The Plan says the enrollee does not have medical need for multiple 
power options included with a K0861 Group 3 power wheelchair. The Plan also says the electronic connection, 
expandable controller harness, and expandable controller cannot be covered as it is not medically necessary to 
control the three requested power options through the joystick (drive interface). 
 
The Plan must follow Medicare rules. Medicare rules say that power seating systems, and PWCs that included 
them, are only covered when specific criteria have been 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 Group 3 PWC with multiple power 
options and the related items. Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found the enrollee has a neurologic disorder with functional deficits. The documentation does not 
indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder or have 
spasticity that would necessitate power tilt or recline. Although the enrollees condition may meet criteria for a 
PWC, the criteria for this specifically requested PWC with multiple power options including power tilt and recline are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Group 3 PWC with multiple power options and the related items have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair (PWC) with multiple power options (K0861) and additional items and accessories (E0955, E1007, 
E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, and E2620).
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 enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
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 cannot be managed at a lower level of care and risks further deterioration 
if not approved for LTACH. 
 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.