Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is 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 the Intracept procedure. Our reviewer 
says that the Intracept procedure is not medically necessary. Our physician reviewer found the Intracept 
procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and 
an electronic connection between wheelchair controller and 2 or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and an electronic connection. 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 power wheelchair accessories are 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 an expandable controller, harness, and 
an electronic connection. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found you have sufficient upper body strength to manage the power drives with standard switches and 
alternative means of control. Therefore, the expandable controller and associated electronics are not medically 
necessary per the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness, and an electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), 
harness (E2313), and an electronic connection between wheelchair controller and 2 or more power seating 
system motors (E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at high risk for falls, increased risk of 
injury and strong potential to decline without IRF. The Plan denied your request. The Plan says the criteria for 
admission to the Acute Inpatient Rehabilitation setting have not been met. The enrollee's ongoing skilled 
therapy and nursing needs can be provided at a lower level of care. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability. The plan has indicated coverage for such a device is 
available upon request. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for SNF 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you have chronic functional loss, daily skilled therapy services are not necessary 
or indicated. There are no daily skilled nursing needs. The criteria for admission per chapter 8 Medicare benefit 
manual not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission 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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with gastric perforation and colonic obstruction that required operative intervention. The record 
indicates that the enrollee has had a complicated hospital course and still requires acute care services. 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 she is not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erbitux. 
 
You asked the Plan to pre-approve Erbitux. You say that the requested Erbitux is medically necessary. The 
Plan denied your request. The Plan says the requested Erbitux 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 Erbitux. Our reviewer says that the 
requested Erbitux is not medically necessary. Our physician reviewer found the requested use of Erbitux is not 
FDA-approved for the enrollee diagnosis. Not in combination with pembrolizumab and Bravtosi. The requested 
use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Erbitux have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Erbitux.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transport provided on January 27, 
2022. 
 
You asked the Plan to pay for the non-emergency ambulance transport.. You say that this transport was 
medically necessary and you have provided medical records to support payment. The Plan denied your request. 
The Plan says this transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance transport.. 
Our reviewer says that this transport was not medically necessary. Our physician reviewer found the 
documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance can provide for safe transport. 
 
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 non-emergency ambulance transport. have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergency ambulance transport provided on January 27, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must either have a history of osteoporosis-related fracture or 
have tried and failed zoledronic acid. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that criteria 
for coverage of Prolia have not been met. Our physician reviewer found the Plan requires either a history of 
osteoporosis-related fracture, or a trial of zoledronic acid first before they will approve the requested drug. In 
this case, the patient has not tried and failed the required drug. There is no documentation provided indicating 
that the plans required drug would likely be less effective and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on February 21, 2022, 
and February 22, 2022. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says these 
self-administered medications not covered under 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 pay for the self-administered drugs 
provided on February 21, 2022, and February 22, 2022.  
 
Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on May 26, 2022, and 
May 27, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you cannot pay this bill and would like 
it to be resubmitted under Part D. The Plan denied your request. The Plan says self-administered drugs are not 
covered under Part B of Original Medicare. 
 
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 pay for the self-administered drugs 
provided on May 26, 2022, and May 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-emergency ambulance ride provided on January 6, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a non-emergency ambulance ride. You say that you waited on the phone in the 
freezing cold for 2 hours after a medical appointment, trying to arrange a ride as cited in the EOC. However, 2 
hours on hold is too long. You then took a ride from another service and gave them the $12. You are seeking 
reimbursement for this amount. The Plan denied your request. The Plan says there was no preauthorization by a 
primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and 
this was not an emergency. Therefore, the decision is upheld. 
 
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 a non-emergency ambulance ride provided on 
January 6, 2020, by an out-of-network (OON) provider.  
 
Your complaint about the Plans ambulance coordinator not picking up the phone, while understandable, is not 
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is necessary due to the 
patient's condition. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
The records show that the noninvasive ventilator will be used in the capacity that another respiratory assistive 
device can provide. The records do not show that the patient has a neuromuscular disease or thoracic restrictive 
disease. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found This patient has a diagnosis of 
chronic obstructive pulmonary disease (COPD), although there are no pulmonary function test results.  An arterial blood gas in April of 2022, at the time of hospitalization for an exacerbation, showed a normal PaCO2 
of 40.4.  The patient is on methadone therapy, which can worsen hypoventilation. However, there is no 
documentation of chronic CO2 retention with arterial blood gas done while stable.  If the patient did have 
chronic CO2 retention, bi-level positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS) could be beneficial, but Medicare does not cover a home ventilator when used as BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional rides due 
to your current medical condition. The Plan denied your request. The Plan says you have already exhausted 
your routine transportation benefit. 
 
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 24 trips per year. There is no provision in your contract for coverage of 
additional trips, regardless of the appropriateness of those transports. 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you have chronic obstructive pulmonary 
disease (COPD) and you cannot breathe. You need this to sleep at night. The Plan denied your request. The 
Plan says this item is not medically necessary. Your records do not show that you need this type of device, a 
different device may meet your needs. You do not have failure of breathing as defined by a blood gas 
measurement. You have not failed CPAP (continuous positive airway pressure) or BiPAP (bilateral positive 
airway pressure) devices. You do not have a restrictive thoracic disease or neuromuscular disease. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found You have severe COPD. However, there is no documentation of chronic carbon dioxide retention on arterial blood gas done 
while stable as an outpatient.  The clinical visit on July 11, 2022, indicates that you already have a Trelegy 
ventilator at home. However, Medicare does not cover a home ventilator when used as BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), scanning computerized ophthalmic 
diagnostic imaging (92134), and determination of refractive state (92015) provided on April 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision care services. You say that you should not have to pay for these 
services. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 rules also say that Medicare generally does not cover 
routine vision and eyewear services. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these services. Additionally, refraction 
services are only covered when billed as part of a routine vision exam. The record indicates that the office visit 
in this case was not for routine vision care. Therefore, we decided that the Plan does not have to pay for the 
office visit (99204), scanning computerized ophthalmic diagnostic imaging (92134), and determination of 
refractive state (92015) provided on April 20, 2022, by an out-of-network (OON) provider.