Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says you are at your 
baseline, and do not have any acute or new medical conditions. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for encephalopathy and urinary tract infection. Your medical 
problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a 
need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation 
therapy program. 
 
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 an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the automatic blood pressure monitor. The Plan denied your request. The 
Plan says an automatic blood pressure monitor is not covered by Medicare. Services considered not reasonable 
and necessary, according to the standards of Original Medicare, are excluded. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on August 26, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on August 26, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced power wheelchair with special features for 
the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says a simpler power wheelchair may meet the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not reveal that the requested special features are medically necessary. The documentation 
does not support a need for tilt and recline power system. The documentation does not indicate that the enrollee 
is at high risk for development of a pressure ulcer, and is unable to perform a functional weight shift; or utilizes 
intermittent catheterization for bladder management or requires a power seating system  to manage increased 
tone or spasticity. It is not reasonable and necessary for the enrolle to have this system. The documentation 
does not reveal the need for other types of proportional input devices (e.g., mini-proportional or compact 
joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head 
array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, 
a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative 
speech device or computer through the chair's drive control), or an attendant control. The enrollee's left upper 
extremity strength and function with independence in feeding are sufficient for the enrollee to control any 
power options through their own individual switches. There is no evidence of a need for adjustable footplates 
as power wheelchair come with foot plates and this would exceed the enrollee's medical need. The appeal states 
that the enrollee needs the drive wheel suspension from the group 3 chair; however, the medical practitioner 
progress notes do not indicate spasticity on an objective exam. The medical provider progress notes do not 
indicate postural asymmetry needing a combination skin protection and positioning seat cushion or a 
positioning cushion. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an advanced power wheelchair with special features for the enrollee.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued FOLFOX chemotherapy with Avastin for the 
enrollee. 
 
You asked the Plan to pre-approve the chemotherapy. You say that this is medically necessary. The Plan denied 
your request. The Plan says the use of this drug regiment requires that the cancer has not grown or spread. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the chemotherapy. Our reviewer says 
that the requested drug is not medically reasonable or necessary. Our physician reviewer found the records 
indicate that the combination has been given since before 8/2020.  A CT scan on 10/5/20 was compared to a 
scan done 2/11/20 and showed enlargement of liver lesions and a nodule in the left lower lung. Therefore the 
enrollee has had progression of the cancer while on the requested treatment. Per DrugDex, Avastin can be 
continued until disease progression or intolerable toxicity. The NCCN Guidelines Version 4.2020 pages COL-
D 1 of 13 and 3 of 13 recommend a change in treatment when there is progression of the cancer. The 
documentation does not support that the requested use of Avastin with FOLFOX is medically reasonable and 
necessary. The documentation does not support that the requested use is safe and effective 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 chemotherapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued FOLFOX chemotherapy with Avastin for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Febuxostat, 80 mg tablet. 
 
You asked the Plan to pre-approve Febuxostat. You say that the enrollee currently takes Febuxostat. You say 
that the enrollee has been stable and seeing improvements for condition. You also say that discontinuing this 
drug would cause frequent flare ups and decrease the enrollee' ability to do daily activities. The Plan denied 
your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under 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 Febuxostat, 80 mg tablet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on June 19, 
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 these services were provided by a Registered Nurse First Assistant (RNFA). The RNFA 
specialty code is 86. CMS does not allow services for an RNFA. A corrected claim can be submitted with a 
valid provider for claim to be reconsidered. This claim cannot be reprocessed for payment until a corrected 
claim is received.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the services were submitted as being 
provided by an RNFA. This is not a Medicare eligible provider. The Plan states a corrected claim would be 
accepted. Therefore, we decided that the Plan does not have to pay for practitioner services provided to the 
enrollee on June 19, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for an ambulance trip provided by a participating 
provider on November 15, 2019. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you do not feel like you owe 
this copayment. The Plan denied your request. The Plan says that the correct copayment has been applied. 
 
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. The Plan has failed to forward the correct 2019 Evidence of Coverage. 
Therefore, we decided that the Plan has to waive the copayment for an ambulance trip provided by a 
participating provider on November 15, 2019.  
 
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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level 
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee 
does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily 
basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient 
basis, in a skilled nursing facility 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not 
covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses provided to the enrollee on March 11, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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. Medicare rules say that DME supplies must be provided with a proof of 
delivery. 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 the denied codes is: 
 
HCPCS L0650: 
 
Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior 
extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), 
produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include 
padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf 
 
HCPCS L3960: 
 
Shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated, includes fitting and 
adjustment 
 
 
 
HCPCS L3916: 
 
Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft 
interface, straps, prefabricated, off-the-shelf 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records provided do not include a valid itemized billing/shipping invoice which details each specific item 
shipped. There is also no proof of delivery matching the billed date of service March 11, 2020, therefore these 
codes cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for orthoses provided to the enrollee on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the is appealing the $72.69 ($17.64 copay + $55.05 
deductible) cost share charged for physician services provided on April 20, 2020. 
 
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan 
denied your request. The Plan says their review determined that the deductible had not been satisfied at the 
time of service. The Plan stated the $72.69 was a combination of $55.05 remaining for the deductible and 
$17.64 for the physician services, which was less than the normal $25 copayment.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you had a deductible 
for 2020 and that after that deductible was met, there was a cost share for specialist services. You have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the is appealing the $72.69 ($17.64 copay + $55.05 deductible) cost share charged for physician 
services provided on April 20, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve Procrit. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Procrit. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Retacrit 
before they will approve the requested drug. It is noted that the plan has already approved Retacrit for 6 
months.  

There has been no trial of Retacrit documented, nor is there documentation that Retacrit is not medically 
appropriate for this enrollee. As such, there is insufficient documentation that an exception to the plan's step 
therapy criteria for coverage of Procrit is 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit (J0885).