Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee arthroplasty (TKA) with inpatient level of 
care. 
 
You asked the Plan to pre-approve the services. You say that the enrollee needs this surgery. The Plan denied 
your request. The Plan says the enrollee has not tried and failed 3 months of conservative therapy. The Plan 
states there is no documentation of a reason for inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. The documentation does not corroborate pain with 
functional disability due to arthritis or trauma to the knee joint; activities of daily living (ADLs) are diminished 
despite compliance with plan of care including activity restrictions as is reasonable, assistive device use, weight 
reduction as appropriate or therapeutic injections into the knee as appropriate. Distinct structural abnormalities were not documented. A previous joint replacement is not documented. Therefore, you do not meet the criteria 
for TKA. 
 
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 total knee arthroplasty (TKA) with inpatient level of care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carotid artery ultrasound (78452, 93880). 
 
You asked the Plan to pre-approve a carotid artery ultrasound. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 carotid artery ultrasound. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support the rationale for this imaging study. 
Guidelines do not support a need for carotid duplex ultrasound imaging. As a result, at this time cardiac 
doppler imaging would not be considered medically appropriate and necessary in this enrollee's clinical management. 
 
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 carotid artery ultrasound have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a carotid artery ultrasound (78452, 93880).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from January 6, 
2024 onward. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on January 2, 2024 with bipolar disorder, most recent episode manic with psychosis, and major 
neurocognitive disorder with behavioral disturbance. Based on the submitted records it is not expected that she 
will improve in a reasonable period of time beyond the dates in question, as she is not showing suicidal or 
homicidal ideation and has no auditory or visual hallucinations. She is compliant with treatment and not 
showing any acute threats to safety. It does not appear that active treatment was taking place beyond the dates 
in question. Continued inpatient services are not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric services from January 6, 2024 onward.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits, and 11 home health 
physical therapy (PT) visits. 
 You asked the Plan to pre-approve home health services. You say that continued skilled nursing visits would be 
beneficial in continuing to assess and monitor for any exacerbations and prevent seeking emergency care or 
being hospitalized. You also say that the enrollee would benefit from continued PT visits to address their 
deficits. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs (i.e., IVs, complex wound care, new IVs, new TFs).  The 
enrollee does not have documented skilled therapy needs.  The enrollee is functioning at a level commiserate 
with a lower level of care (i.e., HEP, outpatient therapy, layperson supervision).  Therefore, the reviewer found 
that the requested home health services are not shown to be medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 home health skilled nursing visits, and 11 home health physical therapy (PT) 
visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. 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. Medicare rules say that PET scans are covered only when they are 
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 a PET/CT scan. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no medical necessity 
documented or explained per National Comprehensive Cancer Network (NCCN) guidelines. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) scan (78815).
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 (tilt/recline, legrests, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that your 
doctor recommended a power wheelchair instead of your current manual wheelchair as you only have one arm. 
You say that your right arm does not work well. You also say that you do not always have someone to push 
you around in your current chair. The Plan denied your request. The Plan says the records do not show 
problems finishing one or more mobility-related activities of daily living (MRADLs) in the home or that you 
have an inability to use a manual wheelchair to complete your MRADLs. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when all the criteria 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found that you do not have high risk for skin 
breakdown, use a catheter intermittently, have spasticity or require an alternative means of managing power 
drive. Therefore, the reviewer found that the requested Group 3 power wheelchair with multiple power options 
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 a Group 3 power wheelchair with multiple power options 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 (tilt/recline, legrests, seat elevator) and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve the drug. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the guidelines for approval of this medication. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
myelodysplastic syndrome (MDS) for whom treatment with Aranesp is requested. MDS was documented by 
bone marrow biopsy on 8/16/2022. The plan is requesting recent iron studies which have not been provided and 
are considered a standard of care with patient receiving erythropoietin such as Aranesp. The requested drug is 
not medically reasonable, necessary, safe, and effective. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2300, 
E2311, E2313, E2322, E2361, E2377, and E2603). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis causing mobility 
limitation for which a Group 3 power wheelchair is medically needed. The Plan also says there is no medical 
need for multiple power options included with a Group 3 power wheelchair code K0861 base. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has chronic respiratory insufficiency, morbid obesity and arthritis. The 
enrollee is able to perform stand pivot transfer. Our reviewer found that the enrollee does not have neurological 
impairment, congenital spine deformity or myopathy. The enrollee has 3 out of 5 strength in their upper 
extremities. Our physician reviewer also found that the enrollee does not have high risk for skin breakdown, 
use a catheter intermittently, have spasticity or require an alternative means of managing power drive. 
 
 
 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 3 standard power wheelchair and additional items 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 multiple power options (K0861) and additional items and accessories (codes E0955, E1007, 
E1012, E1028, E2300, E2311, E2313, E2322, E2361, E2377, and E2603).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE) (36247). 
 
You asked the Plan to pre-approve PAE. You say that the services are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 PAE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found provided medical records and review of the current peer-reviewed medical literature do not 
document that use of PAE has been shown in controlled studies in a CMS-approved journal to result in 
sustained long term health benefits in the Medicare population with benign prostate hyperplasia with outflow 
obstruction.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve prostate artery embolization (PAE) (36247).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on March 17, 2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 service. Our reviewer found the Health Plans denial 
should be upheld. The enrollee was evaluated in the emergency department (ED) for right hallus pain. The 
enrollee was suspected of having osteomyelitis and was hospitalized for antibiotics. An appropriate history and 
physical are documented. The medical decision making was not of high complexity. As such, the billing of 
CPT 99285 is not supported. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit (procedure 99285) provided on March 17, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99284) provided 
on March 3, 2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 service. Our reviewer found the Health Plans denial 
should be upheld. The enrollee was evaluated in the emergency department (ED) after falling and striking their 
head. A scalp laceration was repaired, and the enrollee was discharged. An appropriate history and physical 
were documented. The medical decision making was not of high complexity. As such, the billing of CPT 
99284 is not supported. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit (procedure 99284) provided on March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2300, 
E2311, E2313, E2361, E2377, E2607, E2620, and K0040). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that the patient does meet the criteria as set forth by Medicare for approval of the requested power 
wheelchair. The Plan denied your request. The Plan says the patient does not have medical need for multiple 
power options included with a K0861 Group 3 power wheelchair. The Plan also says an 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 follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the patient has progressive weakness, and has used a power chair for multiple years. 
The patient lives alone, drives, and has intact skin. Our reviewer also found that the patient does not have high 
risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means of 
managing power drive. 
 
 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 3 standard power wheelchair and additional items 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 multiple power options (K0861) and additional items and accessories (codes E0955, E1007, 
E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620, and K0040).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ethos Air Immersion Therapy Mattress. 
 
You asked the Plan to pre-approve an Ethos Air Immersion Therapy Mattress. 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 follows Medicare rules. Medicare rules say that Medicare payment for home use of the air-fluidized 
bed for treatment of pressure sores can be made if such use is reasonable and necessary for the individual 
patient. 
 
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 an Ethos Air Immersion Therapy 
Mattress. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
wounds are healing with conservative management and advanced dressings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Ethos Air Immersion Therapy Mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Ethos Air Immersion Therapy Mattress.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa (J8499). 
 
You asked the Plan to pre-approve Gemtesa. You say that Gemtesa is medically necessity for the patient's 
treatment for overactive bladder. 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. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa (J8499).  
 
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.