Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1852). 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not show evidence of recent injury, surgery or joint laxity with 
knee instability. 
 
The Plan must follow Medicare rules. Medicare rules say that for a knee orthosis to be covered there must be 
documentation of objective joint laxity, instability, recent injury or surgery to the knee.  
 
The documentation does not show any of the covered indications for the knee orthosis. Therefore, we decided 
that the Plan does not have to pay for a knee orthosis (L1852).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. The Plan denied your request. The Plan says the enrollee's 
medical plan does not cover outpatient prescription drugs. 
 
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 Prednisone.  
 
Benefits for Prednisone 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 29, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on January 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a revascularization procedure (37222) provided February 25, 
2020. 
 
You asked the Plan to pay for the revascularization procedure. You say that the services were medically 
necessary. The Plan denied your request. The Plan says documentation does not support the services billed. 
 
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 37222 is 37222 Revascularization, endovascular, open or 
percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty 
 
We find that CPT code 37222 is not supported in the medical record. Specifically, there is no specific 
description of procedures on the left iliac vessels. Based on this information, we decided that Medicare rules 
for coverage of the revascularization procedure have not been met. Therefore, we decided that the Plan does 
not have to pay for a revascularization procedure (37222) provided February 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on January 16, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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 this service. Our reviewer says that Medicare billing criteria were not met. Our physician 
reviewer found the medical records submitted do not include a date of service on the procedural note, therefore 
this service cannot be verified as being performed. In addition, the medical records provided do not include 
documentation of a Fundus photography with interpretation and report, therefore this service cannot be verified 
as performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services provided to the enrollee on January 16, 2020.
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 this is necessary to regain function. The Plan denied 
your request. The Plan says your needs could be met in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. Care at the skilled 
nursing facility level appears to be more appropriate in this case. 
 
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 pay for a knee orthosis with suspension sleeve (L1851, L2397) with 
a joint stabilizer (L2385) provided to the enrollee on April 14, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The record does not contain a valid proof of delivery or relevant medical 
records which support medical necessity for the supplies provided in this case. The documentation submitted 
did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the 
billed date of service. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis 
with suspension sleeve (L1851, L2397) with a joint stabilizer (L2385) provided to the enrollee on April 14, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says your 
condition has improved and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services from November 2, 2020, were requested. 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 continued services. Our physician reviewer found that active treatment was not taking 
place. The services were not reasonably expected to improve your condition, or for the purpose of diagnosis. 
The records were supervised and evaluated by a physician. Based upon review the records provided, you were 
not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations, and 
were cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would greatly benefit from an IRF 
admission so she could receive intensive therapy while being under the close medical oversight of a physiatrist 
and 24/7 nursing care. The Plan denied your request. The Plan says treatment in an acute rehab facility is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does require physical therapy and occupational therapy services, but based on the 
medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. 
Our physician reviewer also found that there is concern that the enrollee will not be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Care at the skilled nursing facility level appears to be more appropriate in this case. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 2, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on January 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery (CPT Codes: 63042, 63056, 63012, 
63005 and 63047). 
 
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria for surgery are not met. There is no documentation of adequate conservative 
measures. There are no red flags for surgery now. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery (CPT Codes: 63042, 63056, 63012, 63005 and 63047).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epclusa tablets. 
 
You asked the Plan to pre-approve the Epclusa tablets. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition by Medicare Part B. 
 
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 Epclusa tablets.  
 
Benefits for the Epclusa tablets 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

I decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) and 
knee stabilizer (L2385) provided to the enrollee on April 14, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  

The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, 
L2397) and knee stabilizer (L2385) provided to the enrollee on April 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L2385) provided to the enrollee on April 13, 
2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a knee orthosis (L2385) provided to the enrollee 
on April 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One injection services. 
 
You asked the Plan to pre-approve the Synvisc-One injection services. You say that the requested drug is 
medically necessary. The Plan denied your request. The Plan says there is no evidence that the enrollee has 
tried the preferred drugs or that there is medical necessity for an exception. 
 
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 the Synvisc-One injection services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a 
trial of drug Orthovisc and Monovisc before they will approve the requested drug.  
 
 
 
 
The records do not show that the enrollee has tried and failed the required drugs. The physician has not stated 
that there is a contra-indication to either of the medications. The request does not comply with step therapy and 
therefore is deemed 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 the Synvisc-One injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Synvisc-One injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ramp. 
 
You asked the Plan to pre-approve a ramp. The Plan denied your request. The Plan says the item is not medical 
in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L2385) provided to the enrollee on April 
6, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the knee orthosis (L2385) provided to the enrollee 
on April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bed rails. 
 
You asked the Plan to pre-approve the bed rails. You say that you fall out of bed a lot and suffer from 
degenerative spine and seizures. You say that you have mobility limitations that significantly affect your ability 
to perform activities of daily living in your home, such as bathing, dressing, and toileting. You say that you 
want the bed rails to help you improve your way of living. The Plan denied your request. The Plan says there is 
no supporting clinical information to indicate the enrollee's mobility status or to confirm that the enrollee has a 
medical condition that requires a hospital bed with bed rails. There is no evidence to show that the requested 
bed rails are required by the enrollee's condition. The requested bed rails are not an integral part of, or an 
accessory to, a covered hospital bed. 
 
The Plan follows Medicare rules. Medicare rules say that bed rails are covered when they are required by the 
beneficiary's condition and they are an integral part of, or an accessory to, a covered hospital bed. 
 
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 the bed rails. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found there is no physician?s order or 
supporting clinical information to indicate the enrollee's mobility status or to confirm a medical condition 
requiring a hospital bed with bed rails. 
 
 
 
 
 
 
 
 
 
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 bed rails have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bed rails.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) as defined by codes 
A4245, A4595, L0650, L1851, L1971, L2397, L3170, L3916, L3960 provided to the enrollee on March 27, 
2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
 
 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) as defined 
by codes A4245, A4595, L0650, L1851, L1971, L2397, L3170, L3916, L3960 provided to the enrollee on 
March 27, 2020.