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

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational procedure which is the subject of ongoing 
clinical trials. 
 
   
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
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 services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 31, 2023. You asked the Plan to pay for the ambulance services. You say that a proper denial is needed in order to bill 
Medicaid. The Plan denied your request. The Plan says transportation to and from a doctor's office is not a 
Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Broda Midline Tilt Recliner 500 (E1399). 
 
You asked the Plan to pre-approve a Broda Midline Tilt Recliner 500. You say that the enrollee did receive a 
wheelchair, however, this is not the proper chair for them, and a new chair is needed. The Plan denied your 
request. The Plan says that the enrollee's current wheelchair is in good condition, and it has been less than 5 
years since the enrollee received the last wheelchair. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Medical records were not provided for this case. We asked for this 
documentation but what was given to us was sparse and does not show that the enrollee's current wheelchair is 
not 5 years old, is not irreparable, or the enrollee's condition has not changed. Without medical records we are 
unable to determine if the criteria for coverage were not met. Therefore, we decided that the Plan has to pre-
approve a Broda Midline Tilt Recliner 500 (E1399).  
 
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 percutaneous injection of allogeneic cellular and/or 
tissue-based product. 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product. 
You say that the enrollee suffers from back pain and has failed conservative treatment. You say that this 
injection is for tissue loss due to disc degeneration and this procedure is indicated for the enrollee's clinical 
condition. The Plan denied your request. The Plan says this 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 percutaneous injection of allogeneic 
cellular and/or tissue-based product. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the service at issue in this case are 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 percutaneous injection of allogeneic cellular and/or tissue-based product have 
not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of 
allogeneic cellular and/or tissue-based product.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria are not met as the pain is multifactorial with 
multilevel disc disease in the lumbar spine. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific 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 L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding the worsening of pain. Additionally, there is no documentation of a progression of the body 
height loss, greater than 25% vertebral body height loss, or kyphotic deformity. Moreover, there is magnetic 
resonance imaging corroboration of other plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria are not met as the pain is multifactorial with 
multilevel disc disease in the lumbar spine. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific 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 L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding the worsening of pain. Additionally, there is no documentation of a progression of the body 
height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, there is magnetic resonance imaging corroboration of other plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service February 21, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the code accurately reflects the treatment 
provided. The Plan denied your request. The Plan says the billed code is 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. 
 
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 physician 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 billed services. Our reviewer found that the enrollee 
was found on his kitchen floor with a 5-centimeter laceration across his right eye. In the emergency 
department, the computed tomography (CT) of the head and neck were normal. The level of medical decision-
making complexity or severity did not require high level based on the documentation. We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99285 billed for date of service February 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Keytruda is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of Stage 1 
non-small cell lung cancer, and the requested drug is first line monotherapy. However, the requested use of 
Keytruda is not FDA-approved. Keytruda is also not supported by one of the major drug compendia or by 
clinical research. Therefore, the elements of the overage criteria are not satisfied, and the requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you disagree with the denial. The Plan 
denied your request. The Plan says our records show that we have already approved the maximum number 
allowed therefore no additional coverage is available 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have cardiac history, cardiac 
disease, and a cardiac stent. You also say that you use the 20/30 compression stockings that the doctors 
prescribed and you like to wear them. The Plan denied your request. The Plan says compression stockings, with 
the exception of these codes A6531, A6532, A6534, A6535, and A6545 are limited to 6 pairs (12 individual 
stockings) per year cumulative total.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an all-lower extremity prostheses, flex-walk system or equal 
(prosthetic foot replacement) and prosthetic socks (L5981, L8420). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee only has one prosthetic, if something 
happens to his current foot, he will be completely immobilized and needs a backup. The Plan denied your 
request. The Plan says that there is no evidence that the requested prosthetics are a medical necessity. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this review indeed finds that these, and all other program integrity criteria, are met for this 
specific enrollee. At the heart of the approval is that bathing is a basic / essential activity of daily living (ADL), 
and it is standard medical / prosthetic practice to provide equipment that facilitates this specific to each enrollee 
when needed. The enrollee's size allows the presumption that he would be essentially unable to fully bath all of 
himself in a seated position, and therefore standing up in the shower is medically necessary, but this enrollee 
cannot safely stand in the shower for any appreciable period of time without a waterproof prosthesis. 
Meanwhile, prosthetic socks, as an inexpensive soft good, need routine replacement; their coverage should not 
be controversial, and is permitted in the LCD and Policy Article in any event. The medical record, consisting of 
the certified prosthetist/orthotist (CPO) note from July, corroborated by primary care physician (PCP) note 
from June, is sufficient documentation justify the request in its entirety. Therefore, L5981x1 and L8420x5 are 
hereby approved for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve an all-lower extremity prostheses, flex-walk system or equal (prosthetic foot replacement) and 
prosthetic socks (L5981, L8420).  
 
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 the ultrasound guidance (76937), provided on April 3, 2023. 
 
You asked the Plan to pay for the ultrasound guidance. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no records have been received to support the services billed 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the ultrasound guidance have been 
met. There were no medical records provided to determine if this service was medically necessary. Therefore, 
we decided that the Plan does not have to pay for the ultrasound guidance (76937), provided on April 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation for your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 60 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 82 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Meningococcal vaccine (90620) provided on March 9, 
2023. 
 
You asked the Plan to pay for the Meningococcal vaccine . You say that the service was medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Meningococcal 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Meningococcal 
vaccine. Therefore, we decided that the Plan does not have to pay for the Meningococcal vaccine (90620) 
provided on March 9, 2023.  
 Benefits for the Meningococcal vaccine  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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve the dental service. You say that you need the braces so you can et and 
swallow. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the comprehensive orthodontic treatment of the adult dentition is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 CGM and supplies. 
 
You asked the Plan to pre-approve the Dexcom G6 CGM and supplies. You say that you prescribed the 
Dexcom system due to the enrollee having variable glucose. The Dexcom system is needed because the Libre 
system is not as accurate as the Dexcom in detecting low blood sugar.  The Plan denied your request. The Plan 
says this would be covered if the enrollee has had an unsuccessful trial of a Freestyle Libre CGM or in a 
situation where they use an insulin pump that is only compatible with the Dexcom CGM. 
 The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands of 
products and this plan only covers Freestyle Libre CGMs 
 
We looked at the file and Medicare rules. Medicare rules say that plans may limit coverage to certain brands of 
products and that the plan only covers FreeStyle Libre CGMs. Based on this information, we decided that 
Medicare rules for coverage of the Dexcom G6 CGM and supplies have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Dexcom G6 CGM and supplies.