Persius/hicric huggingface dataset:
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. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee requires tilt and recline for 
effective weight shifts. The Plan denied your request. The Plan says the enrollee does not require multiple 
power options.  
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair is only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee is functionally non-ambulatory and cannot use a cane or walker for mobility. 
The enrollee cannot functionally propel a manual wheelchair due to upper extremity weakness. The enrollee 
requires a power wheelchair for mobility and accomplishing their daily activities. However, the clinical 
documentation is insufficient why a lower-level power wheelchair would not meet the enrollees needs versus a 
group 3 power wheelchair. There is inadequate clinical documentation regarding why they require power tilt & 
recline and cannot adequately perform pressure relief. There is no history of skin breakdown, and he is noted to 
have 3 out of 5 motor strength in the upper extremities. Therefore, the requested group 3 power wheelchair 
with multiple power options is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 26, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were not properly billed. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (P9603, 84466, 85045) provided on April 12, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the physician must 
clearly document, in the medical record, his or her intent that the test be performed.  
In this case, the CPT Code Manual definition of code P9603 is "Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled". 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the records do not contain 
travel documentation to support this code. Based on this information, we decided that Medicare rules for 
coverage of code P9603 have not been met. Additionally, the documentation submitted does not contain a valid 
physician order or lab requisition for the specific testing (84466, 85045) provided in this case. Therefore, we 
decided that the Plan does not have to pay for the services (P9603, 84466, 85045) provided on April 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire. 
 
You asked the Plan to pre-approve Tezspire. You say that the enrollee has severe asthma and is steroid 
dependent. The Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare 
Part B coverage. 
 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 Tezspire.  
 
Benefits for Tezspire 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts/orthotics (L3000x2). 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee qualifies for, and will benefit from, 
the requested foot inserts during ambulation. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
inserts/orthotics (L3000x2).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132). 
 
You asked the Plan to pre-approve neuropsychological testing evaluation services. You say that in order for 
your patient to receive appropriate diagnosis and treatment, it is your recommendation that they have repeat 
neuropsychological testing. The Plan denied your request. The Plan says this request is not medically necessary 
according to Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that changes in mental illness may require psychological 
testing to determine new diagnoses or the need for changes in therapeutic measures. Repeat testing not required 
for diagnosis or continued treatment would be considered medically unnecessary. Medicare rules also say that 
each psychological test administered must be individually 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 neuropsychological testing evaluation 
services. Our reviewer says that the coverage criteria have not been met. Our physician reviewer found the 
provided records do not document a central nervous system disorder or a concern for a central nervous system 
disorder to support the need for the repeat testing. Our reviewer also found that the provided medical records 
do not fully support the medical necessity of the tests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 1, 2022, 
though September 2, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
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 pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) with diarrhea, abdominal pain, nausea, and 
vomiting following taking anti-diarrhea medication for constipation. She reported the inability to tolerate oral 
intake. The workup revealed low blood pressure, abdominal tenderness, leukocytosis, diverticulitis on  
computed tomography (CT) and she was started on antibiotics, intravenous fluids, and pain medication. 
Following initial treatment at the previous hospital, persistent abdominal tenderness, uncontrolled pain, 
hypotension after fluids, and the inability to tolerate oral intake, it was expected that the enrollee would have 
required a total of at least two midnights of inpatient care including ED 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from September 1, 2022, though September 2, 2022.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the request is medically necessary. The Plan denied 
your request. The Plan says step therapy requirements have not been met. 
 
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 Prolia. Our reviewer says that that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of one 
oral bisphosphonate (such as alendronate or risedronate) and one intravenous bisphosphonate therapy (such as 
zoledronic acid). In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the Plan's required drug(s) would likely be less effective or have 
adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of anesthetic agent or steroid; genicular 
nerve branches (64454). 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you have documentation that 
provides medical necessity. The Plan denied your request. The Plan says the request 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 genicular nerve block. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/investigational therapy. It is the subject of ongoing clinical 
trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the injection of anesthetic agent or steroid; genicular nerve branches 
(64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 9, 2022, billed 
with procedure codes 36247-LT-59 and 75774-26-59. 
 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 codes. 
 
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 codes 36247-LT-59 and 75774-26-59 are column II codes to column I 
code 37226; however, 36247-LT-59 and 75774-26-59 were billed with a modifier.  
 
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 codes. Our reviewer found that an intervention was performed, 
which includes radiological supervision and interpretation, as well as catheter placement. Therefore, the 
procedure codes and modifiers billed cannot be verified. 
 
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 December 9, 2022, billed with procedure 
codes 36247-LT-59 and 75774-26-59.
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 enrollee requires physical therapy services to 
regain their strength. The Plan denied your request. The Plan says the enrollee does not meet the 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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF. The enrollee can receive further services at a lower 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: 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 are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement, however, the documentation does not support that she would meet criteria for 
admission to an acute inpatient rehabilitation facility. The enrollee can receive further services at a lower 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Nalu Peripheral Nerve Stimulation 
(PNS) system. 
 
You asked the Plan to pre-approve implantation of the Nalu PNS system. You did not provide a specific 
argument with your appeal request. The Plan denied your request. The Plan says the clinical value and 
effectiveness of Nalu PNS System in the setting of chronic knee pain have not been demonstrated in the peer-
reviewed literature. There are limited published studies that show this to be an effective and/or safe treatment 
for the noted pathology. 
 
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 implantation of the Nalu PNS system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental/ investigational and is the 
subject of ongoing clinical trials.  Therefore, the request is deemed not medically reasonable and 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 implantation of the Nalu PNS system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implantation of the Nalu Peripheral Nerve Stimulation (PNS) 
system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart device (CCM), an implantable 
pulse generator. 
 
You asked the Plan to pre-approve CCM. You say that the device is medically necessary. The Plan denied your 
request. The Plan says that this device is considered experimental and investigational. 
 
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 CCM. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that while the clinical studies led to Food and Drug Administration (FDA) approval in 2019, 
CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CCM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Optimizer Smart device (CCM), an implantable pulse generator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix skin substitute. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that the wound is at least 1.0 square centimeter in size. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records in this case do not document that the ulcer has failed to improve with 
appropriate wound care measures. The measurements from 8/16/23 to 10/24/23 show a reduction in size of the 
wound. On 08/16/2023 the wound was 2x0.8x0.1 cm in dimensions; on 10/24/2023 it was 1x0.6x0.1 cm in 
dimensions. The latest measurement provided indicates that the wound is 0.6 square cm.  
 
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 Epifix skin substitute.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95971 billed for date of service June 1, 2023. 
 
You asked the Plan to pay for procedure code 95971. The Plan denied your request. The Plan says payment for 
code 95971 is bundled into payment for code 63650.  
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 95971 
is a column II code to column I code 63650. 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 95971 billed for date of service June 1, 2023.