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

 
We decided that the Plan does not have to pay for the Ankle foot orthosis (L1971) provided March 1, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the enrollee's primary care physician prescribed this 
brace withing 6 months of the face to face visit. Medicare would have paid this claim mand the Plan needs to 
pay as well. The Plan denied your request. The Plan says the records do not support the billed service., 
 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 pay for the orthosis. 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 record indicates that the enrollee has ankle and foot pain from a sprain. The 
provided records do not document the need for stabilization of the ankle or foot for medical reasons. The 
elements of the coverage criteria are not satisfied and the requested service cannot be 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 the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the Ankle foot orthosis (L1971) provided March 1, 2022.
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 that the enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently 
receiving but that would be available at the LTACH facility. 
 
   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation to be provided by an out-of-
network (OON) neurosurgeon. 
 
You asked the Plan to pre-approve the office consultation with an OON neurosurgeon. You say that a friend 
saw this requested neurosurgeon and had good results from the surgery. The Plan denied your request. The Plan 
says there are network providers able to provide neurosurgical evaluation. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve services with an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve an office consultation to be provided by an out-of-network (OON) neurosurgeon.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Kadcyla. 
 
You asked the Plan to pre-approve Kadcyla. The Plan denied your request. The Plan says that the criteria has 
not been met. 
 
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 Kadcyla. Our physician reviewer found 
that the requested use of Kadcyla is not FDA-approved for the enrollee's diagnosis. However, the use is 
supported by clinical research that appears in a CMS-approved medical journal. Although not typically 
standard, this enrollee has underlying neuropathy and there is data to support use of Kadcyla with or without 
the addition of endocrine therapy or Pertuzumab. The requested use is not indicated, not supported or not 
recommended in any of the compendia. The documentation does 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 Kadcyla have been met. Therefore, we decided that the Plan has to pre-approve 
Kadcyla.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651) and a segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor. You say that there is no in-network provider that 
carries the pump you are requesting. The Plan denied your request. The Plan says the enrollee must use an in-
network provider for all medical items/services. The Plan also says that the requested item/service is available 
in-network. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exercise equipment (A9300). 
 
You asked the Plan to pre-approve exercise equipment. You say that this is medically necessary and needs to 
be covered to help prevent growth loss. The Plan denied your request. The Plan says exercise equipment is not 
covered as not primarily medical in nature and is not covered under any condition per the Plan's Evidence of 
Coverage. 
 
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 exercise equipment (A9300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve the acute inpatient level of care. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is 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 approve acute inpatient hospital care. Our reviewer 
says that the criteria for coverage are not met. Our physician reviewer found the enrollee is planned for bilateral 
lung volume reduction surgery. The records do not show that an admitting physician may reasonably expect 
that the enrollee will require at least two midnights of the inpatient level of care for the procedure.  
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 not been met. Therefore, we decided that the 
Plan does not have to approve the acute inpatient level of care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology, gross and microscopic examination 
(88308) provided on January 5, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that your services were medically necessary in 
providing a medical diagnosis for the enrollee's referring physician. It is your understanding that outpatient 
procedures are a covered Plan benefit. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the surgical pathology, gross and microscopic 
examination (88308) provided on January 5, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Image Guided Radiation Therapy (IGRT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that 
IGRT is not medically necessary when normal body positioning can adequately limit the amount of radiation. 
 
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 the requested services. Our physician 
reviewer found that in the setting if progression at a limited number of sites in a given line of systemic therapy 
(oligoprogression), local ablative therapy to the oligoprogressive sites may extend the duration of benefit of the 
current line of systemic therapy. While SBRT to sites of oligoprogression would be considered to be within 
accepted standards of medical practice, and this enrollee is planned to receive SBRT, this enrollee is being 
billed for 3DRT since the treatment spans 8 treatments (which is really a billing technicality as SBRT is billed 
as 5 or fewer treatments). While IGRT is bundled with (and therefore not billed for) SBRT it is not bundled 
3DRT. It would be unsafe to treat this patient without IGRT. As the treatment is within accepted standards of 
care, and the billing requires 3DRT billing, IGRT would necessarily be performed and billed as well. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve Image Guided Radiation Therapy (IGRT).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis provided on February 28, 2022. 
 
You asked the Plan to pay for the wrist hand orthosis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item rendered is not documented in the enrollee's 
medical records. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain valid relevant medical records which support medical necessity for the supplies 
provided in this case. Review of the file does not support that the enrollees provider prescribed or considered a 
wrist brace for this enrollee. The documentation does not support that the enrollee had left wrist pain. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on February 28, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure. 
 
You asked the Plan to pre-approve Ensure. You say that the enrollee has unintended weight loss and 
malnutrition. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
We looked at the file and the rules. The items you asked the Plan to pre-approve are considered nutritional 
supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. 
Therefore, we decided that the Plan does not have to pre-approve Ensure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided on December 21, 
2021. 
 
You asked the Plan to pay for a wrist-hand orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a wrist-hand orthosis (L3916) provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osseous surgery (D7950) and a bone replacement 
graft (D7953), provided by a participating provider. 
 
You asked the Plan to pre-approve an osseous surgery and a bone replacement graft. You say that you need 
these services approved. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pre-approve an 
osseous surgery (D7950) and a bone replacement graft (D7953), provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on December 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the lab testing provided on December 28, 2021, by 
an out-of-network (OON) provider.
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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on July 10, 2022 for left prepatellar cellulitis and bursitis and underwent an incision and drainage on 
July 11, 2022. As of July 19, 2022 he is independent with bed mobility and performing activities of daily 
living. The complexity of his nursing medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program at least three hours a day and five days a week, or 15 hours over seven consecutive days. 
There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive 
rehabilitation therapy provided in an inpatient rehabilitation facility. 
 
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 for the refraction (92015) provided on January 31, 2022. 
 
You asked the Plan to pay for the refraction (92015). You say that a $40 charge denied due to an out-of-
network facility even though you were told the facility was in-network. You say that you already paid $543.65 
and are owed a refund. The Plan denied your request. The Plan says the eye exam and imaging were paid. The 
Plan also says a refraction is only covered as part of a routine eye exam.  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 covers a refraction only when billed with a routine eye exam. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the refraction (92015) have not been met. Specifically, the refraction was not performed with a 
routine eye exam. Therefore, we decided that the Plan does not have to pay for the refraction (92015) provided 
on January 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate 2.5 mg tablet. 
 
You asked the Plan to pre-approve Methotrexate. You say that this drug is medically reasonable and necessary 
for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
enrollee's medical 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 Methotrexate 2.5 mg tablet.  
 
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.