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

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that conservative 
treatment has not worked for the enrollee. The Plan denied your request. The Plan says that the enrollee's 
condition does not meet criteria for coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services (92015, 92014) provided on 
July 20, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that you would like the Plan to cover the 
cost of the exam. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 ophthalmological services (92015, 92014) 
provided on July 20, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and supply or accessory for use with 
an implanted ventricular assist device (Q0508) provided on July 29, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for office visit and supply or accessory for use with an implanted ventricular assist 
device. You say that the services rendered were medically necessary. The Plan denied your request. The Plan 
says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 office visit (99214) and supply or accessory 
for use with an implanted ventricular assist device (Q0508) provided on July 29, 2020 by an out of network 
(OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient provided on July 5, 2019. 
 
You asked the Plan to pay for the home visit. You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says the record shows the service was provided by an LVN not a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99348 is Home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face 
with the patient and/or family. 
 
We find that CPT code 99348 is not supported in the medical record. Specifically, there is no documentation 
that the physician who billed was present during the home visit. Based on this information, we decided that 
Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the home visit for the evaluation and management of an established patient provided on July 5, 
2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient hospital stay. 
 
You asked the Plan to pre-approve an inpatient hospital stay. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 an inpatient hospital stay. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found it is medically appropriate to have admitted this enrollee to rule out acute coronary 
syndrome (ACS) given the constellation of her presenting symptoms in the setting of her old age and 
comorbidities. She had abnormal electrocardiogram (EKG) findings with a history concerning for unstable 
angina/ACS. 
 
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 inpatient hospital stay have been met. Therefore, we decided that the Plan 
has to pre-approve an inpatient hospital stay.  
 
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 you believe that IRF care would be best for you. The 
Plan denied your request. The Plan says you do not require intensive rehabilitation services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for total hip replacement due to failure of screw placed during previous surgery in August of 2020. 
Medical problems are stable. There are no identified problems that need inpatient medical management. There 
are no complex nursing or rehabilitation needs. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. 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. 
 
 
 
 
 
 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the immediate upper denture (D5130) 
provided on October 17, 2020. 
 
You asked the Plan to pay the full amount for the upper denture. You say that you were advised you could have 
up to 5 teeth pulled. You say that you had 4 pulled and $90 per tooth should have been paid. You say that you 
cannot afford to pay for these services. The Plan denied your request. The Plan says dentures are not listed as a 
covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the full 
amount for the immediate upper denture (D5130) provided on October 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance (77003) provided December 9, 2019. 
 
You asked the Plan to pay for fluoroscopic guidance. You say that you are requesting claim reconsideration. 
The Plan denied your request. The Plan says this service/procedure requires that a qualifying service/procedure 
be received and covered. The qualifying other service/procedure has not been received/adjudicated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the claim does not indicate any of 
the primary procedures billed for add on code 77003. Add-on codes are always performed in addition to the 
primary service or procedure, and must never be reported as a stand-alone code.  This code cannot be paid as a 
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for fluoroscopic guidance (77003) provided December 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee needs the treatment due to secondary 
diagnosis of ITP. The Plan denied your request. The Plan says Keytruda should only be used when the non-
small cell lung cancer is EGFR/ALK negative. 
 
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 Keytruda. Our physician reviewer 
found that this request for Keytruda to be given with Carboplatin and Paclitaxel to treat metastatic 
adenocarcinoma of lung with PDL1 of less than 1%, and no information regarding EGFR or ALK mutation 
status. The requested use is not FDA-approved. The requested use is not supported in any of the CMS approved 
compendia. The submitted journal articles do not reflect the enrollee's clinical situation. This reviewer did not 
find any supporting citations. The requested use is not listed as not indicated, not supported, or not 
recommended in any of the compendia. The documentation does not support that the requested drug is safe and 
effective and otherwise reasonable and necessary 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PWC repairs. 
 
You asked the Plan to pre-approve the PWC repairs. You say that you are requesting repairs on the PWC. The 
Plan denied your request. The Plan says you are eligible for evaluation of a replacement power wheelchair. 
 
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 PWC repairs have not been met. Your chair is over five years 
with various repair requirement such that you qualify for a new assessment and may qualify for a new 
wheelchair. An extensive repair of a wheelchair over five years does not appear necessary when a new powered 
wheelchair may be needed. An assessment for a possible new wheelchair was scheduled for October 13th, 
2020. Therefore, we decided that the Plan does not have to pre-approve PWC repairs.
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 clinical documentation provided shows that the 
criteria for coverage of IRF care have been met. The Plan denied your request. The Plan says the guidelines for 
coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed 
in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires or can tolerate an intensive rehabilitation therapy program 
provided in an IRF. 
 
 
 
 
 
 
 
 
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 wheelchair accessory, power seat elevation system, any 
type (CPT Code E2300). 
 
You asked the Plan to pre-approve the item. You say that you are requesting review of denial of the item. The 
Plan denied your request. The Plan says the seat elevator does not serve a primary medical purpose and is 
statutorily non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The rules say that a power seat elevation feature (E2300) is non-covered because they are not primarily medical 
in nature. This item is available to the general public and would be helpful even to those who are not sick or 
injured. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessory, power seat 
elevation system, any type (CPT Code E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pressure reducing air mattress (E0277). 
 
You asked the Plan to pre-approve the pressure reducing air mattress. You say that the mattress is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that pressure reducing mattresses are covered when 
medically 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 pressure reducing air mattress. Our 
reviewer says that the mattress is not medically necessary. Our physician reviewer found here is no 
documentation of multiple Stage II or large or multiple Stage III or IV pressure ulcers on the trunk or pelvis. 
There is no record of a mucocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis. 
 
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 pressure reducing air mattress have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pressure reducing air mattress (E0277).
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

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 has a diagnosis of septic shock due to infected chronic right hip pressure injury with osteomyelitis. The enrollee is medically stable at this time, stable hemoglobin and improved white blood cell count. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental procedure in an outpatient setting under 
anesthesia. 
 
You asked the Plan to pre-approve a dental procedure in an outpatient setting under anesthesia. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria has not been met. 
 
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 a dental procedure in an outpatient 
setting under anesthesia. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the services do not meet the coverage 
criteria. Medicare does not provide for routine dental services as are being requested, with dental treatment 
being limited to those circumstances where the dental component is secondary to a primary medical treatment. 
Although the enrollee suffers from Alzheimer's dementia, there is no medical treatment that is primary being 
performed such that dental treatment (usually limited to extractions for preparation for radiation treatment or 
for neoplasms) would be a dependent concern. Under the Plan limitations, the coverage criteria has 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 a dental procedure in an outpatient setting under anesthesia have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a dental procedure in an outpatient setting 
under anesthesia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cyclopentolate eye drops provided on February 5, 2020. 
 
You asked the Plan to pay for self-administered drug. You say that these eye drops were needed to perform 
surgery on your eye. The Plan denied your request. The Plan says the denial of payment for this drug is correct, 
because this drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for cyclopentolate eye drops 
provided on February 5, 2020.  
 
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.