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

 
We decided that the Plan does not have to pre-approve the RYBO Air Balance Custom Brace. 
 
You asked the Plan to pre-approve the RYBO Air Balance Custom Brace. You say that you would like 
reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says 
there is a lack of objective physical exam findings and the lack of a trial with a prefabricated ankle foot 
orthosis. 
 
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 RYBO Air Balance Custom Brace. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the member is ambulatory but the objective exam documentation does 
not reveal objective instability in the foot/ankles or that the member needs this brace for stabilization for 
medical reasons. The member is noted to ambulate without an assistive device and heel and toe walk with ease 
and arise from a seated position without assist. The documentation is conflicting and does not reveal that this  
brace is required to enable the member to benefit functionally. There are no specific maneuvers testing 
instability or objective degrees of range of motion deficits. 
 
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 RYBO Air Balance Custom Brace have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the RYBO Air Balance Custom Brace.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fixed height hospital bed. 
 
You asked the Plan to pre-approve the fixed height hospital bed. You say that you would like reconsideration 
because you had a full electric hospital bed that was approved by your previous Plan. The Plan denied your 
request. The Plan says it was not indicated that you require a bed that needs the head to be elevated, or frequent 
changes in body position, or that you have any equipment that needs to be attached to the bed. 
 
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 fixed height hospital bed. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not clearly reveal that your condition has failed 
positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not 
feasible. The documentation does not support a need for an immediate change in body position or special 
attachments that cannot be fixed on an ordinary bed. The head of the bed does not need to be elevated more 
than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with 
aspiration. 
 
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 fixed height hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the fixed height hospital bed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for DXA (77080) provided on May 18, 2020. 
 
You asked the Plan to pay for DXA. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this service is not indicated for a female without risk 
factors for osteoporosis. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of DXA have not been met. Specifically, the record does not include sufficient information to 
determine if the services rendered met Medicare criteria for coverage. Therefore, we decided that the Plan does 
not have to pay for DXA (77080) provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory services provided on January 1, 2020, through 
May 1, 2020. 
 
You asked the Plan to pay for the respiratory services. You say that you would like reconsideration because this 
is the correct diagnosis code. The Plan denied your request. The Plan says this claim was not billed with an 
appropriate primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory services have not been met. Specifically, this claim was submitted with diagnosis 
code G47.36. G47.36 is a manifestation code and it is inappropriate to bill this as the primary diagnosis code. 
Therefore, we decided that the Plan does not have to pay for the respiratory services provided on January 1, 
2020, through May 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continued SNF care on May 20 to June 14, 2020. 
 
You asked the Plan to pay for continued SNF care. You say that the services which the enrollee required and 
received are coverable under the Medicare Act. The Plan denied your request. The Plan says rules for SNF care 
have 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 pay for continued SNF care. Our reviewer says that 
continued SNF care was not medically necessary. Our physician reviewer found that the enrollee did not 
receive nor require any skilled therapy. There were no identifiable skilled nursing or skilled therapy service 
needs. The enrollee did not require skilled nursing or therapy services on a daily basis.  This enrollee did not 
meet severity of illness or intensity of service criteria for 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pay for continued SNF care on May 20 to June 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), 
with any type side rails, with mattress (CPT Code E0260RR). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the clinical information provided does not show the enrollee meets medical 
necessity criteria for this type of 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 pre-approve the DME. Our physician reviewer 
found based on the medical records provided there is no documentation that a semi-electric hospital bed is 
medically necessary for this patient. The provided medical records do not support that the patient requires 
frequent and immediate need for a change in body position as outlined in Medicare's LCD L33820. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), with 
any type side rails, with mattress (CPT Code E0260RR).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Avastin (J9305) 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 sources don't support the use of this drug/regimen to treat stage IV EGFR+ non-
small cell lung cancer. 
 
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 drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found Bevacizumab is FDA 
approved for the first line treatment of unresectable, locally advanced, recurrent or metastatic nonsquamous 
non-small cell lung cancer (in combination with carboplatin and paclitaxel). Patients that progress on first line 
Tagresso are treated as if they are receiving first line therapy. The plan is to discontinue the Tagresso. The 
service is reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Avastin (J9305) 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. 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. 
 
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 Gel-One. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires 
these be trialed first. The documentation does not outline contraindications or reasons these medications were 
not considered or that the plan?s required drugs would likely be less effective and/or likely have adverse effects 
for the enrollee. Without the support of the documentation, Gel-One is not approved as step criteria 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated in a lower level of care. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to currently be able to perform fifteen hours per week of rehabilitative 
services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. 
SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the office visit and x-ray provided on 
June 20, 2019. 
 
You asked the Plan to make additional payment for the medical services. You say that you are being billed for 
the difference between the provider's bill and the plan's payment. You state that from what you understand the 
plan should be paying the full amount. The Plan denied your request. The Plan says it was decided to waive 
your cost sharing requirements and pay the full Medicare allowable to the provider. The noncontract provider 
should not bill you for the difference as the Medicare allowable is payment in full for these services.  
 
The Plan must follow Medicare rules. Medicare rules say that noncontract providers must accept Medicare 
payment rates as payment in full for services rendered to a Medicare enrollee.  
 
In this case, the Plan has paid the full amount allowed by Medicare for the services at issue. Neither you nor the 
Plan are required to pay more than this amount. Therefore, we decided that the Plan does not have to make 
additional payment for the office visit and x-ray provided on June 20, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve high frequency chest wall oscillation system, includes all 
accessories and supplies, each (CPT Code E0483). 
 
You asked the Plan to pre-approve the device. You say that without the use of the E0483 device, the member 
faces serious life-altering condition and that the member qualifies for this request. The Plan denied your 
request. The Plan says that the device is not 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 device. Our physician reviewer 
found the patient with significant chronic respiratory problems, has COPD and diaphragm disorder and 
recurrent complications. Hospitalizations are both costly and add to morbidity. Our physician reviewer feels 
that the device may reduce hospitalizations and feels l it is indicated based on guidelines and is medically 
reasonable and 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 device have been met. Therefore, we decided that the Plan has to pre-
approve high frequency chest wall oscillation system, includes all accessories and supplies, each (CPT Code 
E0483).  
 
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: Unfavorable

We decided that the Plan does not have to pre-approve Fluorouracil intravenous (IV) solution 500mg/10ml 
injection (CPT Code J9190). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found there is no compendia, no local coverage determination and no high quality literature to support. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Fluorouracil intravenous (IV) solution 500mg/10ml injection (CPT Code J9190).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), expandable controller (E2377), and a harness for 
upgrade to expandable controller (E2313). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors, expandable controller, and a harness for upgrade to expandable controller. You 
say that the items 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 certain criteria must be met for expandable 
controllers to be covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection between 
wheelchair controller and two or more power seating system motors, expandable controller, and a harness for 
upgrade to expandable controller. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found based on the medical records provided there is no documentation that the enrollee meets the 
coverage criteria. Based on the provided records her left upper limb strength and function appear to be 
adequate to be able to control the power options using their own switches which are included in the allowance 
of the power options. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection between wheelchair controller and two or more power 
seating system motors, expandable controller, and a harness for upgrade to expandable controller have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), expandable controller (E2377), 
and a harness for upgrade to expandable controller (E2313).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox 600 units per 90 days (64615, J0585). 
 
You asked the Plan to pre-approve Botox 600 units per 90 days. You say that the service requested is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the dosage requested is not 
medically accepted. 
 
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 Botox 600 units per 90 days. Our 
reviewer says that the service requested is not medically necessary. Our physician reviewer found the 
documentation does not support that a dose of 400 units has been ineffective for this 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 Botox 600 units per 90 days have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Botox 600 units per 90 days (64615, J0585).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the CMS guidelines for authorization. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
may benefit from BiPAP at night. However, Medicare does not cover a  home ventilator when used as BiPAP; 
certain BiPAP devices can provide the AVAPS-AE mode of support that has been ordered.  There is no 
demonstrated failure of BiPAP. A home ventilator is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.