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

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system (K0108). 
 
You asked the Plan to pre-approve a transit system. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a transit system does not serve a purpose that is medical in 
nature and is used for convenience purposes. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is 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 a transit system (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management service (99239) 
provided on March 16, 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 record does not support the service billed. 
 
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 99239 is the hospital discharge day management service. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, CPT code 99239 is a time 
based code. In order to bill CPT code 99239, the documentation must note that more than thirty minutes was 
spent providing services to the enrollee on the day of discharge. The progress note for March 16, 2020 does not 
note how much time was spent providing this service to the enrollee. As such, the provided documentation does 
not support the billing of CPT code 99239. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for the 
hospital discharge day management service (99239) provided on March 16, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. 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 does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to his cognitive impairment and resistance to therapy. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 25, 2019, by an OON 
provider. 
 
You asked the Plan to pay for a specialist office visit. You say that this service was part of services needed 
prior to surgery. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 has pre-approved coverage for 
this provider effective June 19 to December 31, 2019. The date of service at issue in this appeal falls outside 
the range of the Plan's pre-approval. 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 medical services provided on 
April 25, 2019, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fabrazyme. 
 
You asked the Plan to pre-approve Fabrazyme. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Fabrazyme. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found in this case, the clinical notes do not 
provide confirmatory genetic tests for Fabry disease. The review indicates that the documentation does not 
support that the Fabrazyme is medically reasonable and necessary or safe and effective 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 Fabrazyme have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Fabrazyme.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on 
November 15, 2020 with left eye vision loss, headache, and dizziness. He is weak on the left side and unsteady 
and is working with physical and occupational therapy. He is walking 50 feet with a rolling walker with contact 
guard assistance and is contact guard assist to supervision for transfers and minimal assist for activities of daily 
living. He is reported to be medically stable for discharge. The complexity of his nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. He does not require an intensive therapy program 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide Epogen/Procrit. 
 
You asked the Plan to provide Epogen/Procrit (J0885). You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says the enrollee does not meet the standards for this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 provide Epogen/Procrit (J0885). Our reviewer says 
that the drug is not medically necessary. Our physician reviewer found the diagnosis has not been confirmed. 
Epogen is not approved to treat, 'possible myelodysplastic syndrome,' nor to treat anemia of undetermined 
origin. As such, the off-label use of this drug to treat this condition is not medically 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 Epogen/Procrit (J0885) have not been met. Therefore, we decided that the Plan 
does not have to provide Epogen/Procrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra Test Strips for the enrollee. 
 
You asked the Plan to pre-approve One Touch Ultra Test Strips. You say that the requested supplies are 
medically necessary. The Plan denied your request. The Plan says One Touch Ultra Test Strips are not a 
preferred brand covered by the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay must use specified manufacturers for diabetic supplies. The requested brand is not a preferred band 
covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Test 
Strips for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androgel. 
 
You asked the Plan to pre-approve Androgel. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Androgel.  
 
Benefits for Androgel 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits. 
 
You asked the Plan to pre-approve home health visits. You say that leaving your home to receive these services 
involves potential exposure to COVID-19 which could be fatal. The Plan denied your request. The Plan says 
the denial of authorization for home health care is correct, because you have no need for skilled services, are 
not homebound, and have no treatment plan. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA). 
 
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 the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left knee pain due to 
primary osteoarthritis. Genicular nerve ablation is considered investigational in nature and is not reasonable or 
medically necessary for the treatment of chronic knee 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. The 
clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and 
improve with, LTACH services. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve private duty nursing services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not covered by Medicare or the plan. 
 
The Plan must follow Medicare rules. The rules say that the services of a private-duty nurse or other private-
duty attendant are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve private duty 
nursing services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 48 one-way allotted trips 
for the 2020 benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that this should be covered. The Plan 
denied your request. The Plan says the criteria for coverage has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices are covered when the beneficiary 
is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous 
subcutaneous insulin infusion (CSII) pump. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee is treated with three or 
more daily injections of insulin. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

     
We decided that the Plan does not have to pre-approve physician or other qualified health care professional 
attendance and supervision of HBO therapy, per session (CPT Code 99183). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee does not have a covered condition for HBO therapy. 
 
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 services. Our physician reviewer 
found at this time, more teeth that cannot be restored have been identified and need extraction. Request now is 
for ten (10) hyperbaric oxygen treatments after extraction. The twenty (20) treatments before extraction are said 
to be not needed as the changes from the 20 earlier this year are anticipated to be maintained. It is noted that the 
Marx protocol was developed specifically to reduce the incidence of osteoradionecrosis of the mandible after 
dental extraction and not to treat soft tissue radio necrosis for which no surgical procedure is required. Per the 
Medicare coverage criteria, HBO therapy is approved for the treatment of Soft tissue radionecrosis as an 
adjunct to conventional treatment. Use of this therapy is not listed as being approved in the absence of 
osteoradionecrosis. The review has determined that the medical records provided do not meet the requirements 
listed in the NCD for Medicare coverage. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physician or other qualified health care professional attendance and supervision of HBO 
therapy, per session (CPT Code 99183).
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on 
October 17, 2020 with abdominal pain. He is weak and deconditioned and is working with physical and 
occupational therapy. He is walking with minimum to moderate assistance with a rolling walker with frequent 
rest breaks and is moderate to maximum assist for transfers and maximum assist for some activities of daily 
living. He is reported to be medically stable for discharge. The complexity of his nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. He does not require an intensive therapy program 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF care from November 17, 2020, through November 
24, 2020. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on the documentation provided, the health plan's denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform fifteen (15) hours per week of rehabilitative services or to require regular physician evaluation. Your 
care needs can be met at 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF care from November 17, 2020, through November 24, 2020.