Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the requested ILR is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for an ILR. 
 
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 ILR. Our reviewer says that the 
enrollee does not meet criteria for an ILR. Our physician reviewer found there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollees 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza. 
 
You asked the Plan to pre-approve Qutenza. You say that the requested Qutenza is medically necessary. The 
Plan denied your request. The Plan says the requested Qutenza 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 Qutenza. Our reviewer says that the 
requested Qutenza is not medically necessary. Our physician reviewer found the requested use of Qutenza is 
not FDA-approved for the enrollee's diagnosis. The use of the requested drug is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Qutenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Qutenza.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) (77523). 
 
You asked the Plan to pre-approve PBRT. 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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based upon the provided records it is not plausible that proton therapy would provide a 
clinically meaningful benefit over a well-designed Intensity modulated radiation therapy (IMRT) plan. While 
not experimental, its potential benefit over non-proton based radiation is an investigational question. Thus, proton therapy is not necessary as it would not meet ASTRO or NCCN criteria and therefore would not be 
furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT) (77523).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service January 17, 
2023. 
 
You asked the Plan to pay for procedure code 99213. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99213 is bundled into payment for code 29075. 
 
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 99213 
is a column II code to column I code 29075. 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 99213 billed for date of service January 17, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the requested ILR is medically necessary.  The Plan 
denied your request. The Plan says the enrollee does not meet criteria for an ILR.  
 
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 ILR. Our reviewer says that the 
enrollee does not meet criteria for an ILR.  Our physician reviewer found the enrollee had no history of atrial 
fibrillation, nor were any significant cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. A 
recent randomized clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed 
by treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in 
reducing stroke or systemic embolism among patients at high risk of stroke but without a known prior history 
of atrial fibrillation. At this time, insertion of an ILR would not be considered medically appropriate and 
necessary in this enrollees 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional routine transportation trips 
 
You asked the Plan to pre-approve the 10 additional routine transportation trips. You say that you are asking 
for an additional 10 one-way transportation trips to go to your appointments.  The Plan denied your request. The Plan says your benefit plan simply does not cover more than 10 one-way trips per plan year. You have 
currently used 8 or your 10 allowed/covered on-way trips. The Plan will approve 2 additional trips to complete 
the 10 covered trips. 
 
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 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve an 
additional 10 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 8 additional routine transportation trips
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  electronic connection between wheelchair controller 
and one power seating system motor identified with code E2310. 
 
You asked the Plan to pre-approve  electronic connection between wheelchair controller and one power seating 
system motor. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that electronic connection between wheelchair 
controller and one power seating system motor is only covered for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the request is for upgraded electronics. 
The documentation does not support a medical need to control the power options through the joystick. The 
power options can be controlled using their own switches. Based on this information, we decided that Medicare 
rules for coverage of electronic connection between wheelchair controller and one power seating system motor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve  electronic connection 
between wheelchair controller and one power seating system motor identified with code E2310.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health physical therapy (PT) visits.  

You asked the Plan to pre-approve the home health PT services. You say that it is felt that both the skilled 
nursing and PT are required by the enrollee.  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 the home health PT services. Our 
reviewer says that the home health PT services are not medically reasonable and necessary. Our physician 
reviewer found the records show that the enrollee has some cognitive loss but is independent in gait and 
transfers. There are no specific treatment goals noted for PT. As such, the documentation does not support the 
need for the requested PT.  
 
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 home health PT services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 9 home health physical therapy (PT) visits.
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 and recline) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that you 
are unable to walk properly. You also say that you want to appeal this denial. The Plan denied your request. 
The Plan says the documentation does not support the need for power tilt and recline. The Plan says there is no 
medical need for the upgraded electronics. The Plan says the EZ lock does not serve a medical purpose and 
cannot be covered. The Plan also says the seat belt is already included in the requested wheelchair.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain 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 request for a Group 3 power wheelchair with multiple 
power options is not medically necessary. Our physician reviewer found the provided documentation does not 
support that you are high risk for skin breakdown, has a history of pressure ulcer(s) or has had skin flap 
surgery. The reviewer found that the records do not document that you perform bladder self-catheterization and 
are unable to transfer independently or that you have increased muscle tone or spasticity to meet criteria for the 
multiple power options/power tilt and recline. Therefore, the reviewer found that the request for a Group 3 
power wheelchair with multiple power options is not medically reasonable or necessary. As the power 
wheelchair base does not meet criteria for coverage, the requested accessories are not covered. 
 
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 and recline) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, above knee or hip 
disarticulation, knee extension assist (L5850). 
 
You asked the Plan to pre-approve the item. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the item denoted by code L5850 is not a proper 
component of the requested knee. 
 
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 item. Our physician reviewer found 
the L5850 addition endoskeletal system, above knee or hip disarticulation, knee extension assist exceeds the 
enrollee's medical needs and is not medically necessary per LCA A52496. Codes L5828, L5845, L5848 and 
L5856, are the codes to be used for Otto Bock Kenevo. The requested item is not medically necessary for the 
Otto Bock Kenevo knee.  
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the addition, endoskeletal system, above knee or hip disarticulation, knee extension assist 
(L5850).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that medical records were provided. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99220. 
 
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 99497 is a column II code to column I code 99220. Code 99497 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 99497 
billed for date of service March 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a transthoracic echocardiography. You say that the requested transthoracic 
echocardiography is medically necessary. The Plan denied your request. The Plan says the requested 
transthoracic echocardiography 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 transthoracic echocardiography. Our 
reviewer says that the requested transthoracic echocardiography is not medically necessary. Our physician 
reviewer found the enrollee has no cardiac signs or symptoms. Documentation at this time would not point to a 
change in status that would support the medical necessity of a repeat TTE. Clinical guidelines do not support 
repeating a TTE with no intervening change in clinical status or new signs, symptoms, or physical findings. In summary, there is no supportive evidence for the medical necessity of repeat TTE in this this enrollees 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 transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiography (TTE).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation at T10 (22513). 
 
You asked the Plan to pre-approve a percutaneous vertebral augmentation. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that this procedure is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PVA is covered when it is medically necessary for 
enrollees with painful, debilitating, osteoporotic vertebral collapse/compression fractures that meet all the 
coverage 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 a percutaneous vertebral augmentation. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that there is no 
trial of fracture bracing. More conservative measures are needed. 
 
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 percutaneous vertebral augmentation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation at T10 (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514).  
You asked the Plan to pre-approve kyphoplasty. 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 Percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain 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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation of a trial of 
fracture bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies billed for date of service December 
13, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support the denied units. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are relevant 
medical records which support medical necessity.  
 
The claim at issue shows that 120 units of code A6196 was billed. For the claim at issue, the record does not 
contain relevant medical records which support medical necessity for the excess supplies billed. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the wound care supplies billed for date of service December 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided October 24, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that please find attached documents and 
reprocess your claim. The Plan denied your request. The Plan says if you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency room services provided 
October 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that the patient has significant side effects to 
multiple medications, so massage therapy would be a safer alternative to medication treatment. The Plan denied 
your request. The Plan says massage therapy is not a covered benefit 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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. 
 
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. Our reviewer says that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the record indicates 
that the enrollee has chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that the enrollee was treated with bilevel positive airway pressure (BiPAP) in the hospital.  The 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-
assured pressure support (AVAPS) capability and failure of such a device has not been documented.  The plan 
has indicated coverage for such a device is available upon request. The elements of the coverage criteria are not 
satisfied.  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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.