Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve the OON services. You say that the requested facility is close enough to get
your radiation therapy. The Plan denied your request. The Plan says services are available with contracted
providers.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We were able to confirm that the Plan has
contract providers located within reasonable distance and travel time from your home who can provide the
requested services. We found no exception that would require the Plan to pre-approve these OON services.
Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by an out of
network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for Rituxan administered on December 5, 2019 and pre-approve future
treatments.
You asked the Plan to pay for the Rituxan. You say that you would like reconsideration because this treatment
is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan
says that these services are subject to prior authorization requirements.
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 pay for the Rituxan. Our reviewer says that there is
sound data that supports the use of Rituximab in this member, more importantly, this member has responded
positively to this therapy. Our physician reviewer found Rituximab is standard of care, necessary, and has been
successful in the management of this member.
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 Rituxan have been met. Therefore, we decided that the Plan has to pay for
Rituxan administered on December 5, 2019 and pre-approve future treatments.
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 the services are 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 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 is generally medically stable and the documentation does not support that
he has complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical,
medicine, and rehabilitation (PMR) physician three times per week. While the enrollee may benefit from
continuing physical therapy (PT) and occupational therapy (OT), the documentation does not support that there
is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an
interdisciplinary approach to rehabilitation care. It is not clear that the enrollee 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing identified with code 81545.
You asked the Plan to pre-approve genetic testing. 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 a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that genetic testing identified with code 81545 is noncovered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to preapprove
genetic testing identified with code 81545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electronic connection.
You asked the Plan to pre-approve the electronic connection (E2311). You say that the enrollee needs to
control the options through the joystick. The Plan denied your request. The Plan says the enrollee has the
ability to use the included switches to control the options.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. The documentation indicates the enrollee has sufficient functional
ability in the upper extremities to control the power features through their own individual switches. Based on
this information, we decided that Medicare rules for coverage of the electronic connection (E2311) have not
been met. Therefore, we decided that the Plan does not have to pre-approve the electronic connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot orthotic (L3020).
You asked the Plan to pre-approve foot orthotics. You say that two years ago you got orthotics for your feet
and they were covered but last year you had a hip replacement and a knee replacement and the feet changed
and the orthotics do not work anymore. You state you need new ones to fit the changes in your knee and hip.
The Plan denied your request. The Plan says Medicare only covers foot orthotics if it is a part of shoes provided
for severe diabetic foot disease or if itis part of a brace.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Your appeal tells us that you are having foot pain (Plantar Fasciitis) and you need orthotics. Records show that
you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be
appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore,
we decided that the Plan does not have to pre-approve the foot orthotic (L3020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Arjo Sara 3000 with transfer sling (E0637).
You asked the Plan to pre-approve an Arjo Sara 3000 with transfer sling. You say that you would like the plan
to review your DME denial of obtaining an Arjo Sara 3000 with transfer sling. The Plan denied your request.
The Plan says this item is not durable medical equipment and is not covered by Medicare or the plan.
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 an Arjo Sara 3000 with transfer sling (E0637).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 units per month for indwelling catheter, foley type,
two-way latex with coating (A4338) insertion tray without drainage bag and without catheter (A4310).
You asked the Plan to pre-approve the additional urological supplies. You say that you request reconsideration
of these supplies because they are required to avoid all complication and avoid putting the enrollee at risk of
infections. The Plan denied your request. The Plan says the records do not support the medical necessity for
additional urological supplies.
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 additional urology supplies. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found based on the clinical documentation, there is no report of any treatment for
UTI. There is also no documentation to show malfunctioning of the catheter, accidental removal of catheter,
obstruction of catheter or recurrent issues such as obstruction/encrustation that would require additional
preventative change of catheter. The coverage criteria for more than one catheter per month have not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the additional urology supplies have not been met. Therefore, we decided that
the Plan does not have to pre-approve 2 units per month for indwelling catheter, foley type, two-way latex with
coating (A4338) insertion tray without drainage bag and without catheter (A4310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM) (K0554)
and supplies (K0553).
You asked the Plan to pre-approve a Dexcom CGM and supplies. You say that you feel this device would
benefit you. The Plan denied your request. The Plan says you do not meet criteria for coverage of this device.
The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered by
Medicare when the beneficiary has been using a BGM and testing four or more times a day and the beneficiary
is insulin-treated three or more daily injections of insulin.
We looked at the file and Medicare rules. The records show that you are not testing your glucose four or more
times a day and that you are insulin-treated with three or more daily injections. Based on this information, we
decided that Medicare rules for coverage of a Dexcom CGM and supplies have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM) (K0554) and
supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of the home portable oxygen
equipment.
You asked the Plan to pre-approve continued rental of the home portable oxygen equipment. You say that you
cannot breathe correctly without the portable oxygen equipment. The Plan denied your request. The Plan says
there is no recent analysis of your oxygen levels to meet medical necessity criteria but you are approved for an
evaluation.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.
To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.
We looked at the file and Medicare rules. There is no recent record of blood gas levels. Based on this
information, we decided that Medicare rules for coverage of continued rental of the home portable oxygen
equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve continued
rental of the home portable oxygen equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuromuscular electrical stimulation (NMES) device
(E0770). You asked the Plan to pre-approve NMES device. You say that you strongly disagree with the
conclusion and respectfully request reconsideration of this determination. The Plan denied your request. The
Plan says the records do not support that the enrollee meets the Medicare criteria for the FES device.
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 NMES device. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found in this case the member has a history of lumbar spinal stenosis and a possible motor
neuronopathy. He has been prescribed a functional electrical stimulation (FES) for his right foot drop.
However, the member in this case does not have a history of a spinal cord injury (as defined by) and as
required by the NCD for coverage of a FES unit. Consequently, the requested FES device would not meet the
NCD requirements for coverage 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 NMES device have not been met. Therefore, we decided that the Plan does not
have to pre-approve neuromuscular electrical stimulation (NMES) device (E0770).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 99220 and 99217 provided on December 24,
2019 and December 25, 2019.
You asked the Plan to pay for CPT codes 99220 and 99217. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly
reported with other procedure codes as a result of the misuse of the column two code with the column one code
are not payable as there are limited circumstances when the column two code may be reported on the same date
of service as the column one code. Therefore, we decided that the Plan does not have to pay for CPT codes
99220 and 99217 provided on December 24, 2019 and December 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) sensors.
You asked the Plan to pre-approve CGM sensors. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that sensors are only covered when they are being
used with a therapeutic CGM.
We looked at the file and Medicare rules. Review of the file shows that the requested sensors are being
requested for a non-therapeutic CGM. Based on this information, we decided that Medicare rules for coverage
of CGM sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve
continuous glucose monitor (CGM) sensors.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81162, 81436).
You asked the Plan to pre-approve the genetic testing procedures. You say that the tests are medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. The enrollee has no
medical condition that supports testing.
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 genetic testing procedures. Our
reviewer says that the requested testing is not medically necessary. Our physician reviewer found there is no
documentation that the enrollee in this case has symptoms or a medical condition necessitating testing. The
tests at issue in this case are screening tests in nature.
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 genetic testing procedures have not been met. Therefore, we decided that the
Plan does not have to pre-approve genetic testing (81162, 81436).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) with supplies
(K0553, K0554).
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM is medically necessary. The
Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when the beneficiary is
insulin-treated with multiple (three or more) daily injections of insulin.
We looked at the file and Medicare rules. The record shows the enrollee is not treated with insulin injections.
Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been
met. Therefore, we decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM)
with supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic care.
You asked the Plan to pre-approve chiropractic care. The Plan denied your request. The Plan says the coverage
criteria are not met.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
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 chiropractic care Our reviewer says that
the requested chiropractic care is not medically reasonable and necessary for the enrollee in this case. Our
physician reviewer found that there are no submitted imaging studies to reveal evidence of a subluxation. Thus,
chiropractic treatment is neither supported nor allowed per Medicare guidelines.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of chiropractic care have not been met. Therefore, we decided that the Plan does
not have to pre-approve chiropractic care.
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 you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says you do not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. Medicare rules also say that therapeutic CGMs are covered only
when a patient has been performing four or more blood glucose tests every day and is insulin-treated with at
least three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion
(CSII) pump. The file shows that you do not test your blood glucose levels at least four or more times a day and
you do not inject insulin at least three or more times per day. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five home health skilled nursing visits.
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. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has been receiving home
health services since December 4, 2019 after a myocardial infarction. The records do not support that the
enrollee requires home health skilled nursing for setting up medications. Skilled nursing services are not
required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or
to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration.
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 five home health skilled nursing visits.