Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Feraheme. 
 
You asked the Plan to pre-approve the drug. You say that Feraheme is medically necessary for the treatment of 
chronic iron deficiency anemia. The Plan denied your request. The Plan says that Feraheme is not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 
Feraheme is medically necessary. Our physician reviewer found that the requested use of Feraheme is FDA-
approved. Feraheme is also safe and effective and otherwise reasonable and necessary 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Feraheme.  
 
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 an electronic connection (E2311), expandable controller 
harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, and expandable 
controller. You say that the enrollee needs this equipment. The Plan denied your request. The Plan says the 
electronic connection, expandable controller harness, and expandable controller cannot be covered as they are 
not medically necessary to control the three approved power options through the joystick (drive interface). 
 
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 an electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the provided records 
document that the enrollee has fair functional control of their bilateral upper extremities and no difficulty 
with eating thus indicating they have adequate upper extremity strength and function to operate the 
wheelchairs power options with their own switches. 
 
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 electronic connection, expandable controller harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), expandable controller harness (E2313), and expandable controller (E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is severely debilitated and 
will require physical therapy, occupational therapy, speech therapy and wound care. You say the LTACH will 
be able to attend to all the enrollee's ongoing needs for them to have a meaningful recovery. The Plan denied 
your request. The Plan says the records do not show that the enrollee has intense medical needs. The enrollee's 
continued care needs include therapy and nutrition. When the enrollee is ready to leave the hospital, they can 
receive this care in another setting.  
 
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 that the enrollee does not require services at the LTACH that are not available at 
the acute care hospital. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing, four or more 
contiguous teeth or bounded teeth per quadrant (D4341) and inhalation of nitrous oxide/anxiolysis, analgesia 
(D9230) provided on July 26, 2023.  
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the periodontal scaling and root planing has already been exhausted. 
Inhalation of nitrous oxide/anxiolysis is not a covered service. 
 
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 periodontal scaling and root planing was exhausted on date of service September 12, 2022. Inhalation of nitrous oxide/anxiolysis is not a covered service. Therefore, we decided that the Plan does 
not have to pay for periodontal scaling and root planing, four or more contiguous teeth or bounded teeth per 
quadrant (D4341) and inhalation of nitrous oxide/anxiolysis, analgesia (D9230) provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy (EGD). 
 
You asked the Plan to pre-approve esophagogastroduodenoscopy. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it 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 esophagogastroduodenoscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollees provider has acknowledged the risk to appellant of 
colonoscopy surveillance. The medical necessity and appropriateness of another EGD as requested is further 
not supported by the clinical documents received.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of esophagogastroduodenoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve esophagogastroduodenoscopy (EGD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one 70/70A circuit breaker battery cable for 24 Volt 
(24V) electric (K0108), one 24V 2 Foot UE1 charge cable extension with 3pin XLR (K0108), one charger 
cable (K0108), and repair/service for power wheelchair change (K0739). 
 
You asked the Plan to pre-approve a circuit breaker battery cable, a charge cable extension, charger cable, and 
repair/service for power wheelchair change. The Plan denied your request. The Plan says the changes to your 
battery system cannot be approved because they are considered to be convenience items. 
 
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 circuit breaker battery cable, a charge 
cable extension, charger cable, and repair/service for power wheelchair change. 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 indicate that the requested repairs have a 
medical purpose therefore they are 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 a circuit breaker battery cable, a charge cable extension, charger cable, and 
repair/service for power wheelchair change have not been met. Therefore, we decided that the Plan does not 
have to pre-approve one 70/70A circuit breaker battery cable for 24 Volt (24V) electric (K0108), one 24V 2 
Foot UE1 charge cable extension with 3pin XLR (K0108), one charger cable (K0108), and repair/service for 
power wheelchair change (K0739).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of ventricular assist device, percutaneous, 
including radiological supervision and interpretation; left heart, arterial access only (Impella LVAD) (33990). 
 
You asked the Plan to pre-approve insertion of LVAD device. You say that this is medically necessary. The 
Plan denied your request. The Plan says medical necessity criteria not met, as most recent ejection fraction is 
greater than 60%. 
 
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 insertion of LVAD device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee's LV ejection fraction is 60% and the enrollee does not have 
New York Heart Association (NYHA) Class IV heart failure. As such, guidelines for placement of an LVAD in 
this setting 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 insertion of LVAD device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion of ventricular assist device, percutaneous, including radiological 
supervision and interpretation; left heart, arterial access only (Impella LVAD) (33990).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479-GZ billed for date of service 
November 8, 2022. 
 
You asked the Plan to pay for the billed service. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says the service is not payable with the billed modifier. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 81479-GZ is not supported. Claim lines billed with a GZ modifier are automatically 
denied and not subject to complex medical review. Based on this information, we decided that Medicare rules 
for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 81479-GZ billed for date of service November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections with moderate sedation. 
 
You asked the Plan to pre-approve the injections with moderate sedation. You say that given that the procedure 
requires delicate and precise placement of the needles, it is necessary that the enrollee be able to lay still 
without sudden movement. The Plan denied your request. The Plan says facet joint injections with moderate 
sedation are 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 injections with moderate sedation. 
Our reviewer says that facet joint injections with moderate sedation are not medically necessary. Our physician 
reviewer found that there is no medical necessity for the use of conscious sedation and MAC for the requested 
cervical facet joint injections. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 injections with moderate sedation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve facet joint injections with moderate sedation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a facet joint 
injection 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 injection. Our reviewer says that a 
facet joint injection is not medically necessary. Our physician reviewer found that the first lumbar medial 
branch block (MBB) on September 22, 2023, provided 70% pain relief. Therefore, the enrollee does not meet 
the LCD coverage criteria. 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a facet joint injection.
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 is being referred and recommended to 
IRF to be assessed both medically and functionally in regards to their premorbid functional capacity to 
determine whether they can benefit from a rehabilitation level of care. The Plan denied your request. The Plan 
says based on Medicare guidelines, the inpatient rehabilitation facility services requested do not meet the 
requirements for approval.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for frequent falls. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee was prescribed a home 
ventilator in August of 2023, and it have been a lifesaver. You say that it has improved the enrollee's quality of 
life.  The Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient 
because their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that there is no 
evidence or data to support BiPAP failure or requirements for a home ventilator. While the enrollee does have 
severe COPD, there is no indication that a home ventilator is the best practice. Also, there is no arterial blood 
gas test to support deterioration in respiratory status or need for a home ventilator. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified oral surgery procedure (D9999) provided on 
April 6, 2023. 
  
You asked the Plan to pay for the dental service. You say that you would like the Plan to cover the surgery 
services at 100% because there were no oral surgeons within your service area. The Plan denied your request. 
The Plan says the denial of payment for this service is correct, because the unspecified oral surgery procedure 
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 Plan's 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 pay for the 
unspecified oral surgery procedure (D9999) provided on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) for tooth #2 
provided on August 1, 2023. 
  
You asked the Plan to pay for the dental service. You say that you called prior to going to your dentist office to 
make sure the crown was covered. The Plan denied your request. The Plan says the denial of payment for this 
service is correct because implant and all related services are not covered by the Plan. Also, it was verified that 
you did not call the Plan prior to the date of service to verify dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for the 
custom fabricated abutment (D6057) for tooth #2 provided on August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service August 14, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99070 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on April 4, 2023, 
to, June 2, 2023. 
 
You asked the Plan to pay for the office visit. You say that that the claim should be reconsidered. The Plan 
denied your request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on April 4, 2023, to, June 2, 2023.