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

 
We decided that the Plan does not have to pre-approve Group 3 power wheelchair upgraded electronics. 
 
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller 
harness (E2313), and Expandable controller (E2377). You say that you need the proper chair or you will get 
more sores. The Plan denied your request. The Plan says the electronic upgrades cannot be covered as it is not 
medically necessary to control the three approved power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if 
the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is 
medically necessary. 
 
The documentation indicates that you have sufficient functional ability in the upper extremities to control the 
power features through their own individual switches. This means that Medicare rules for coverage of upgraded 
electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve Group 3 
power wheelchair upgraded electronics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ibrance tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 Ibrance tablets.  
 
Benefits for self-administered drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that denying this drug may cause a decline 
in the enrollee's health and well-being. The Plan denied your request. The Plan says the denial of authorization 
for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer 
the enrollee's Medicare Part D prescription drug benefits. 
 
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 Pantoprazole tablets.  
 
Benefits for self-administered drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine patches. 
 
You asked the Plan to pre-approve Buprenorphine. You say that this is the only way to transition off 
oxycodone. The Plan denied your request. The Plan says this medication does not fall under 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 Buprenorphine patches.  
 
Benefits for Buprenorphine 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility admission. 
 
You asked the Plan to pre-approve a skilled nursing facility (SNF) admission. You say that the enrollee needs 
SNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 a skilled nursing facility (SNF) 
admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this 
patient 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 patient has no complex wound care or other skilled nursing need. The patient's functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled 
nursing or therapy services are not required on a "daily basis" or as a practical matter 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 a skilled nursing facility (SNF) admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a skilled nursing facility admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says rules for the LTACH services have not 
been met. 
 
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) 
for pancreatitis. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. 
 
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 the LTACH services.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is the best course for member's continued
recovery. The Plan denied your request. The Plan says that the enrollee is stable to discharge to another 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 in the Medicare rules section.

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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a
femur fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record
supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wireless heart failure monitor. 
 
You asked the Plan to pre-approve Implantable wireless pulmonary artery pressure sensor with delivery 
catheter, including all system components (C2624) and Transcatheter implantation of wireless pulmonary 
artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the 
sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and 
interpretation, and pulmonary artery angiography, when performed (33289). You say that the wireless heart 
failure monitor is medically reasonable and necessary. The Plan denied your request. The Plan says the services 
are considered experimental, investigational or unproven. 
 
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 Implantable wireless pulmonary artery 
pressure sensor with delivery catheter, including all system components (C2624) and Transcatheter 
implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including 
deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, 
radiological supervision and interpretation, and pulmonary artery angiography, when performed (33289). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the efficacy of the wireless heart failure monitor system remains uncertain 
at this time. Further clinical study is needed to determine the efficacy and safety of this device. It is not clear 
that the device is medically reasonable and necessary for the enrollee 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 Implantable wireless pulmonary artery pressure sensor with delivery catheter, 
including all system components (C2624) and Transcatheter implantation of wireless pulmonary artery 
pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, 
right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and 
pulmonary artery angiography, when performed (33289) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the wireless heart failure monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital stays.

You asked the Plan to waive the copayments for inpatient stays. You say that you had to wait several days in
the hospital for a COVID test result to come back so you should not have to pay these amounts. The Plan
denied your request. The Plan says the copayment amounts you are being charged are correct.

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 must pay $465
copayment per day for days 1 to 4 for each in-network inpatient stay. The inpatient stay lasted 3 days, resulting 
in a copayment of $1,395. The inpatient stay also lasted 3 days, resulting in a copayment of $1,395. Your total
copayment obligation is therefore $2,790.

You have been asked to pay $465 copayment per day for days 1 to 4 for each inpatient stay. Inpatient stays fall
within the Inpatient Hospital Care benefit category. This means that 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 copayments for
inpatient hospital stays.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two units of an epidural injection (CPT code 64520), for 
the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is for the treatment of coccydnia. The Plan 
denied your request. The Plan says no long-term studies have shown benefit other than case series and thus 
large studies are 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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found criteria for epidural injection not met. The literature does not support epidural injections for 
coccidynia and sacral bone pain. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve two units of an epidural injection (CPT code 64520), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device surgery.

You asked the Plan to pre-approve Vertiflex device surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex device surgery. 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 back pain. The Vertiflex device is experimental. More research is needed to show safety and efficacy. Open laminectomy is the gold standard treatment for spinal stenosis. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex device surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device surgery.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the ConfirmMDx molecular assay provided on October 19, 2020. 
 
You asked the Plan to pre-approve the ConfirmMDx testing. You say that the testing was medically necessary 
and should be covered. The Plan denied your request. The Plan says that this is not covered when done at the 
same time as the initial biopsy. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx is considered medically necessary for 
men with previous negative prostate biopsy who remain at elevated risk.  
 
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 ConfirmMDx testing. Our reviewer 
says that the documentation supports that this testing was reasonable and necessary in this case. Our physician 
reviewer found the enrollee was evaluated for elevated prostate markers and underwent trasnrectal ultrasound 
for needle guided biopsy. This ConfirmMDx testing was ordered due to a negative result in order to judge the 
need for repeat biopsy. The criteria for coverage of the ConfirmMDx testing have been met 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 the ConfirmMDx testing have been met. Therefore, we decided that the Plan 
has to pre-approve the ConfirmMDx molecular assay provided on October 19, 2020.  
 
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 pay for the self-administered drugs.

You asked the Plan to pay for the self-administered drugs. You say that you do not feel that you should be held
responsible. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B
of Original Medicare.

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 pay for the self-administered drugs.

Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services, including an office visit and extraction, 
from an out of network dental provider. 
 
You asked the Plan to pre-approve dental services that will be provided out-of-network.. You say that you want 
a doctor that you feel you can trust, and that this doctor is rated higher than in-network providers. The Plan 
denied your request. The Plan says dental services provided by an out-of-network provider are excluded from 
coverage. There are local in-network providers who are able to provide the required dental care. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, services provided out-of-network are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services, including an office visit and extraction, from an out of network dental provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 5, 2020, by an 
OON provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were 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 requested provider in this case is not a network provider with the Plan. The referring provider is not a 
network provider with the Plan. The Plan had network providers available who could have provided the 
items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no 
exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does 
not have to pay for the laboratory services provided on November 5, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on October 13, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on October 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care rendered on August 8, 2019, to August 9, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the billed services exceed the MUE. 
 
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 states that the claim was billed in excess of the medically unlikely edits 
(MUE) for code 99233; however, there is no documentation of the number of MUE billed. Therefore, we 
decided that the Plan has to pay for the subsequent hospital care rendered on August 8, 2019, to August 9, 
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.