Persius/hicric huggingface dataset:
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 the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Everolimus. 
 
You asked the Plan to pre-approve a tier exception for Everolimus. You say that the exception is needed. The 
Plan denied your request. The Plan says the drug does not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Everolimus have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tier exception for Everolimus.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and segmental 
pneumatic appliances (E0667). 
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliances. 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 follows Medicare rules. Medicare rules say that a segmented, calibrated gradient pneumatic 
compression device (HCPCS code E0652) is only covered when the individual has unique characteristics 
which prevent them from receiving adequate satisfactory pneumatic compression treatment using a 
nonsegmented device along with a segmented appliance or compression device without manual control of the 
pressure in each chamber. 
 
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 pneumatic compressor and segmental 
pneumatic appliances. Our reviewer says that the services are not medically necessary.  
 Our physician reviewer found in this case the record indicates that the enrollee has lymphedema from chronic 
venous insufficiency that does not extend onto the trunk or abdomen. This indication is excluded by rule. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 pneumatic compressor and segmental pneumatic appliances have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and 
segmental pneumatic appliances (E0667).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after April 
22, 2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that continued SNF care is medically 
necessary. The Plan denied your request. The Plan says continued SNF care after April 22, 2022, is not 
medically necessary because your needs can be met at a lower level of care. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled 
nursing or skilled therapy needs at this time. You do not require these services on a daily basis in an inpatient 
SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care after April 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. 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 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 Methotrexate. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Methotrexate is not FDA approved for 
the treatment of cutaneous squamous cell carcinoma (SCC) or supported by major drug compendia. Limited 
data in the literature for the treatment of advanced SCC not amenable to surgical management. The rationale 
for methotrexate is not provided. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Methotrexate have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Methotrexate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy. 
 
You asked the Plan to pre-approve percutaneous laminotomy. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee is not enrolleed in a clinical study. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for dates of service specified below, the 
Centers for Medicare & Medicaid Services (CMS) has determined that PILD will be covered by Medicare 
when provided in a clinical study under section 1862(a)(1)(E) of the Social Security Act (the Act) through 
Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved 
clinical study that meets the criteria. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of percutaneous laminotomy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous laminotomy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the heart (93306) provided on January 28, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that this claim should be paid. The Plan denied your 
request. The Plan says you had another company as your primary insurer on the date in question and should 
direct your claim to this company first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made 
outreach to the provider and yourself regarding where to send the bill. As the secondary insurer, the Plan 
cannot be held responsible for the ultrasound until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the ultrasound of the heart (93306) provided on 
January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 11, 2021, to July 
14, 2021, as billed with Diagnosis Related Group (DRG) 193. 
 
You asked the Plan to pay for inpatient care billed with DRG 193. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 193 is not 
supported as the secondary diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical 
record. The Plan argues that DRG 194 may be more appropriate in this case. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 193. Our 
reviewer says that the diagnosis of metabolic encephalopathy (G93.41) is not supported in the record. Our 
physician reviewer found that the enrollee was admitted and treated for pneumonia. Metabolic encephalopathy 
was listed as a diagnosis. However, the records stated that the enrollee had a baseline dementia (Alzheimer's), 
she was awake and oriented three times, and there was insufficient support found in the documentation that 
suggested the enrollees mental status was worse than baseline to an extent that would meet the definition of 
metabolic encephalopathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 193 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from July 11, 2021, to July 14, 2021, as 
billed with Diagnosis Related Group (DRG) 193.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on November 8, 2021. 
 
You asked the Plan to pay for initial hospital care. You say that these services were billed correctly and are 
supported in the medical record. The enrollee was seen by two different specialists. The Plan denied your 
request. The Plan says this service was billed with Place of Service (POS) code 21 for an inpatient hospital 
setting; however, the records do not support that the enrollee was inpatient status at this time. Therefore, the 
POS code billed for this claim is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. In this case, the services were billed with POS 
code 21 - inpatient hospital. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the medical record indicates 
that the enrollee was observation status at the time of services rather than inpatient. Based on this information, 
we decided that Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided 
that the Plan does not have to pay for initial hospital care (99223) provided on November 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 30, 2021, to 
September 2, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were necessary. The Plan 
denied your request. The Plan says that the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the provided documentation showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 30, 2021, to September 2, 2021.  
 
 
 
 
 
 
 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 outpatient physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 8 PT visits. You say that completing PT per the physician-approved plan of 
care would assist in her goal to avoid knee replacement surgery. The Plan denied your request. The Plan says 
the requested PT visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 8 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided documentation does not indicate the requested therapy is 
generally accepted as specific and effective therapy for the enrollee's condition. The reviewer found that the 
records do not demonstrate that the unique skills of a professional therapist are required to provide treatment 
safely and effectively, that the services can be safely and effectively performed only by a therapist, or for 
physical therapy and occupational therapy, by or under the supervision of a therapist. The reviewer also found 
that the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
Therefore, the reviewer found that the requested PT visits are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 8 outpatient physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy to be given in conjunction with Nivolumab. 
 
You asked the Plan to pre-approve Yervoy. You say that you would like Ipilimumab to be given in conjunction 
with Nivolumab to be given as a third line of therapy for the enrollee. The Plan denied your request. The Plan 
says this request for Yervoy is being denied because Malignant poorly differentiated neuroendocrine tumors, 
small cell lung cancer is not a medically accepted indication. 
 
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 Yervoy. Our reviewer says that Yervoy 
to be given in conjunction with Nivolumab is not medically reasonable and necessary for the enrollee. Our 
physician reviewer found the requested use of Yervoy to be given in conjunction with Nivolumab is not Food 
and Drug Administration (FDA) approved for the enrollees diagnosis. Our reviewer found that the use is not 
supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & 
Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that the use is not 
listed as not indicated, not supported or not recommended in any of the compendia.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yervoy to be given in conjunction with Nivolumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye exam (92014) and an eye refraction (92015) 
provided on October 11, 2021, to October 21, 2021. 
 
You asked the Plan to pay for a routine eye exam and an eye refraction. You say that you had multiple eye 
exams for cataracts. The Plan denied your request. The Plan says you have exceeded the benefit plan allowed 
amount for this service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says you receive one routine eye exam each calendar year. 
 
We looked at the file and the Plan's rules. The EOC confirms you receive one routine eye exam per calendar 
year. The records show you received a routine eye exam on April 27, 2021; therefore, you have exhausted your 
maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a 
routine eye exam and an eye refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for a routine eye exam (92014) and an eye refraction (92015) provided on October 11, 2021, to October 21, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 21, 2022. 
 
You asked the Plan to pre-approve SNF care after April 21, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 SNF care after April 21, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF 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 SNF care after April 21, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injections of the left knee. 
 
You asked the Plan to pre-approve the Orthovisc injection services. You say that the records provided support 
the need for the injection services which remain in dispute. The Plan denied your request. The Plan says there 
is no documentation of complaints of left knee pain, diagnostic imaging confirming left knee osteoarthritis, 
physical therapy for left knee pain, or intraarticular injection to the left knee. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Orthovisc injection services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no 
documentation of left knee arthritis or failure of conservative therapy. The Plan has approved the Orthovisc 
injection for the right knee. The review has determined that the documentation does not support that the left 
knee Orthovisc injection is medically reasonable and necessary for the enrollee. The documentation does not 
support that the left knee Orthovisc injections are safe and effective for the 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 the Orthovisc injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Orthovisc injections of the left knee.