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

 
We decided that the Plan does not have to pre-approve a lift chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 lift chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81599) provided on August 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81599) provided on August 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service April 10, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 93010 is bundled into payment for code 12001. 
 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, we have confirmed that code 93010 
is a column II code to column I code 12001. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service April 10, 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 you feel the enrollee's medical condition 
meets LTACH requirements and the level of care is necessary for them to function at optimal level. The Plan 
denied your request. The Plan says the member is receiving appropriate in-patient acute care and is currently 
unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to currently be unstable and requires short-term additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for transfer. 
The enrollee does not require services at the LTACH that are not already available at the current facility. 
Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time. 
Completion of treatment at the current facility is 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wig. 
 
You asked the Plan to pre-approve the wig. You say that the enrollee suffers from alopecia universalis and 
medically benefits from being able to wear a wig. The Plan denied your request. The Plan says the wig is not 
considered durable medical equipment (DME) because it does not directly treat a medical problem. The Plan 
states it also does not meet the Medicare definition of a prosthetic because it does not replace an internal body 
organ or attached tissue. 
 
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 the wig.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear device implantation. 
 You asked the Plan to pre-approve the requested services. You say that a cochlear implant on the left side will 
help restore hearing. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a cochlear implantation is only covered under certain 
medical indications.  
 
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 the enrollee has sensorineural hearing loss and a left vestibular schwannoma removal. The 
medical records document a left sided hearing loss and right-sided normal hearing with mild to moderate 
SNHL, 0% WRS (word recognition score) on the left, and a 100% WRS on the right. The records do not 
document a limited benefit from amplification for his left or right sided hearing loss. Therefore, the request is 
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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cochlear device implantation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low air loss mattress. 
 
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 a low air loss mattress is covered when specific 
criteria are met.  
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 submitted records do not document 
that the enrollee has multiple stage two pressure ulcers located on the trunk or pelvis that have failed to 
improve over the past month. There is no documentation of large or multiple stage three or four pressure ulcers 
on the trunk or pelvis, a myocutaneous flap, or skin graft for a pressure ulcer on the trunk or pelvis in the past 
60 days. The criteria for coverage are not met and the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a low air loss mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Libre Freestyle 3 device. 
 
You asked the Plan to pre-approve a Libre Freestyle 3 device. You say that the requested device helps with 
your ability to maintain a healthy A1C level. During your trial period that your doctor supplied, you were able 
to get your A1C from 13 down to 8 because you were able to closely manage it. You would like this decision 
reversed as you believe it is the best route for you. Your provider also believes it to be the best therapeutic 
treatment for you as well. The Plan denied your request. The Plan says the requested system is not considered 
eligible for coverage by Medicare or the plan, nor is it included among the list of benefits under your Part B 
coverage. 
 
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 records show that the requested device is not a covered benefit 
with Medicare. The Freestyle Libre 3 is not currently eligible for Medicare reimbursement. Based on this 
information, we decided that Medicare rules for coverage of a Libre Freestyle 3 device have not been met.  
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve a Libre Freestyle 3 device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve Ubrelvy. You say that the enrollee is unable to take triptans due to 
uncontrolled hypertension. You say that the enrollee has taken Nurtec but it was not effective. You also say 
that the enrollee has responded well to this drug. The Plan denied your request. The Plan says this drug is not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy.  
 Benefits for Ubrelvy 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic. 
 
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 current clinical guidelines for adult 
stroke rehabilitation and recovery designate robotic therapy to be of "uncertain utility compared with dose-
matched conventional upper limb exercise therapies" with unproven benefit in the home environment. In 
addition, provided records report the enrollee has severe spasticity of the left upper extremity, which may be a 
contraindication to use of the device. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion G orthotic.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the therapy and machines they use are 
helping you get better. You say that you do not have access to this type of therapy at home and that continuing 
therapy will help you with your balance. The Plan denied your request. The Plan says an additional 3 physical 
therapy 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 physical therapy. 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 that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. You have no recent injury or a decline in function. The 
additional therapy services are not appropriate duration and frequency for treatment of your medical condition 
and therefore 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 3 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on August 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 pay for the anesthesia services rendered on August 24, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custodial care provided by a participating provider. 
 
You asked the Plan to pay for custodial care. You say that you would like the Plan to reimburse you. The Plan 
denied your request. The Plan says custodial care is not covered under any condition. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for custodial care 
provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this is medically necessary. 
The Plan denied your request. The Plan says this serves the same purpose as an item you already have. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a portable gaseous oxygen system. A portable gaseous oxygen system serves the 
same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-
approve a portable oxygen concentrator (E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical shoulder arthroscopy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show how long conservative therapies were tried. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested left shoulder arthroscopy, decompression of the subacromial space with 
partial acromioplasty, and a rotator cuff repair, in this case, is not medically reasonable or necessary. Detailed 
documentation is not evident regarding a trial and failure of recent, reasonable, comprehensive less invasive 
conservative care measures. The documentation notes physical/occupational therapy and cortisone injections 
are alleviating factors of the symptoms. There is no further documentation indicating when she has tried these 
conservative measures and that they have failed. Moreover, the MRI dated 11/15/22 did not corroborate a 
rotator cuff tear. Impingement syndrome is not corroborated by objective findings as her left shoulder range of 
motion is intact. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
 
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 surgical shoulder arthroscopy.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Kenalog injection (J3301) provided on December 6, 2021. 
 
You asked the Plan to pay for the injection. You say that this drug is a medically necessary part of the 
enrollee's treatment. The Plan denied your request. The Plan says that the injection is not medically necessary. 
 
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 pay for the injection. Our reviewer says that the 
Kenalog injection was medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee has failed conservative therapy. Therefore, the reviewer found that injection was 
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 the injection have been met. Therefore, we decided that the Plan has to pay for 
the Kenalog injection (J3301) provided on December 6, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that the requested Imfinzi is medically necessary. The Plan 
denied your request. The Plan says the requested Imfinzi is not medically necessary. 
 
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 Imfinzi. Our reviewer says that the 
requested Imfinzi is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of Stage IV oligometastatic lung adenocarcinoma with solitary brain metastasis that 
is MSS/pMMR, PDL1 negative, EGFR/BRAF/ERBB2/ALK/ROS/RET/MET/NTRK all negative; KRAS 
pG12C mutation. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's specific clinical condition.  The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's specific clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 12, 2022, to 
June 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 12, 2022, to June 
10, 2022.