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

 
We decided that the Plan does not have to pay for orthopedic shoes and sales tax (L3215, S9999, A9270) 
provided March 4, 2020. 
 
You asked the Plan to pay for the orthopedic shoes and sales tax. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the orthopedic shoes were provided from a provider 
that does not participate in Medicare and is not the provider that billed for the brace. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or provider who has opted out of the program except in 
cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider does not participate in the Medicare program. Therefore, we decided that the Plan does not have to 
pay for orthopedic shoes and sales tax (L3215, S9999, A9270) provided March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management 
infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies 
and equipment (drugs and nursing visits coded separately), per diem (S9328) provided from September 10, 
2019, through February 6, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says this payment as you have coded is not a covered benefit under the enrollee's Medicare 
and health plan. The Plan states they suggest the doctor re-submit the claim for payment with a payable code. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Medicare guidance says status code 
I Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these 
services. Therefore, we decided that the Plan does not have to pay for home infusion therapy, implanted pump 
pain management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem (S9328) provided from 
September 10, 2019, through February 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response services provided to you on May 16, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says ambulance transport 
was not provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 16, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response services provided to you 
on May 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transport (A0430, A0435) provided March 16, 
2020. 
 
You asked the Plan to pay for the air ambulance transport. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the enrollee was stable for transport by ground ambulance. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport. Our reviewer 
says that air ambulance transportation was not medically necessary. Our physician reviewer found based on the 
records the enrollee appears to have been stable for traditional ambulance transport. At no point in the records 
reviewed did it appear that air transport was indicated. 
 
 
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 air ambulance transport have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance transport (A0430, A0435) provided March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the 
out of network (OON) provider on April 30, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on 
April 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy guidelines were not followed. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial 
of oral/intravenous bisphosphonates (Zoledronic Acid) before they will approve the requested drug. In this 
case, you have not tried and failed the required drug. There is no documentation provided indicating that the 
plan?s required drug would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia 60mg/ml syringe.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left sacroiliac joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the requested services. You say that you are in severe pain. The Plan denied 
your request. The Plan says ablation for sacroiliac joint pain is considered experimental. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain 
medical 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 the requested services. Our physician 
reviewer found that you have chronic low back pain related to lumbar spondylosis, lumbago with sciatica, 
lumbar spondylosis, spinal enthesopathy thoracolumbar region, and status post (s/p) sacral fusion surgery. You 
are s/p prior bilateral medial branch nerve RFA at the thoracic spine level. According to the literature, sacral 
lateral nerve branch blocks and ablations/neurotomies for the diagnosis or treatment of sacroiliac joint 
mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, 
whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational. The 
review has determined that the requested injection is not safe and effective. The requested service is not 
medically reasonable or necessary to treat your condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left sacroiliac joint radiofrequency ablation (RFA).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that a CardioMEMS device is medically 
necessary. Your doctor said that you are enrolled in a clinical trial to demonstrate the effectiveness of the 
system in dispute. The Plan denied your request. The Plan says current medical literature indicates that the 
service being requested is considered experimental and investigational. The Plan says that the CardioMEMS 
device is not identified as widely used and generally accepted for the proposed use. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that Original Medicare pays for the routine costs of qualifying 
clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people 
enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original 
Medicare and the plan cost-sharing for the same 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 CardioMEMS 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 has a history of hypertension, atrial fibrillation, stroke, nonischemic 
cardiomyopathy, biventricular pacemaker and NYSHA Class III congestive heart failure with reduced LV 
ejection fraction (LVEF 24%) requiring hospitalization. Therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy.  Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and is not recommended in current guidelines for the treatment of heart failure. The device 
should still be considered experimental or investigational. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS device.  
 
Please note, your doctor argued that you are involved in a clinical trial for this device. The Plan is not 
responsible for routine costs associated with qualifying clinical trials.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have a qualifying diagnosis for a group 3 power wheelchair. 
 
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 you have no 
skin issues, and no impaired gross fine motor skills. Your mobility limitation is not due to a neurological 
condition, myopathy, or a congenital skeletal deformity therefore the criteria for a Group 3 power wheelchair 
have not been 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 the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group three power wheelchair.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat upper endoscopy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an upper endoscopy is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records show that you have a 
history of bleeding peptic ulcer disease, irritable bowel syndrome, and an annular pancreas. The note dated 
August 12, 2020 shows you reported symptoms of soreness on your side, excessive gas, cramping, and a dull 
ache in the stomach area. You continue to have symptoms despite an adequate course of therapy. The requested 
repeat upper endoscopy is reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve a repeat upper endoscopy.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a microscope during nerve surgery for the 
enrollee. 
 
You asked the Plan to pre-approve the microscope. You say that this is medically necessary. The Plan denied 
your request. The Plan says separate payment for the use of the microscope is not allowed by Medicare 
guidelines. 
 
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 microscope. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no need to bill extra for a microscope for this routine lumbar decompression procedure. 
The procedure can be performed safely without the microscope. 
 
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 microscope have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of a microscope during nerve surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a second opinion consultation with an out of network (OON) 
ophthalmologist. 
 
You asked the Plan to pre-approve the OON ophthalmology consultation. You say that you wish to see a 
provider not affiliated with the network doctor group to get an independent second opinion about your 
condition. The Plan denied your request. The Plan says that there are other providers at this office who can 
provide the second opinion you are requesting. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may restrict enrollees to network providers 
for most services as long as all medically necessary care is available from this network. OON care must be 
arranged for services not available in-network. 
 
In this case, we find that an independent second opinion is not available within your network. The providers 
offered are colleagues within the same provider group. Since there is no other network option outside of this 
provider group, we find that OON specialty care must be arranged by the plan. Therefore, we decided that the 
Plan has to pre-approve a second opinion consultation with an out of network (OON) ophthalmologist.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia 60 mg/ml subcutaneous syringe for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the information from the provider does not show a trial of zoledronic acid. 
 
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 drug. Our reviewer says that the 
requested drug is medically reasonable or necessary. Our physician reviewer found the review indicates that the 
plan requires a trial of zoledronic acid before they will approve the requested drug. In this case, the enrollee has 
not tried and failed the required drug.  However, step therapy may only be applied to new prescriptions or 
administrations of Part B drugs for enrollees that are not actively receiving the affected medication.  The 
enrollee has received previous Prolia therapy. The plan's required drug would likely be less effective and/or 
likely have adverse effects for the enrollee. The requested Prolia is medically necessary and reasonable. 
 
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 
Prolia 60 mg/ml subcutaneous syringe for the enrollee.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have 
not been met. The Plan says that the enrollee's needs can be managed at the current setting or in a skilled 
nursing facility. 
 
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 the enrollee presented to the acute hospital on September 18, 2020, with diabetic 
ketoacidosis, unresponsiveness, seizures and bilateral pneumonia. He was treated in the hospital with 
intubation, mechanical ventilation, intravenous antibiotics and insulin in the intensive care unit. The enrollee 
has had a tracheostomy placed, is being fed via a percutaneous feeding tube, is suffering from global anoxic 
encephalopathy and is obtunded and responsive only to painful stimuli. The short-term acute care hospital can 
provide for all the enrollee's present inpatient care needs. The enrollee is receiving an appropriate level of care 
in the presenting setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is 
stable to transfer to a lower level of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.