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

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable 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 follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) 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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has severe obesity and develops acute hypercarbic and hypoxic respiratory failure 
secondary to COVID pneumonia. She required intubation and tracheostomy. Mild carbon dioxide (CO2) 
retention continued after extubation, on bilevel positive airway pressure (bipap). Obesity hypoventilation 
syndrome is suspected. The enrollee does not have chronic obstructive pulmonary disease (COPD), 
neuromuscular disease, or thoracic restrictive disease. This enrollee may benefit from bipap during sleep. The 
average volume-assured pressure support (AVAPS) mode of support can be delivered via bipap. 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Citalopram. 
 
You asked the Plan to pre-approve Citalopram. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Citalopram.  
 
Benefits for Citalopram 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a new or replacement of permanent 
pacemaker. 
 
You asked the Plan to pre-approve insertion of a new or replacement of permanent pacemaker. 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 cardiac pacemakers 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 insertion of a new or replacement of 
permanent pacemaker. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found there is insufficient documentation to support the medical necessity for insertion of a pacemaker in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a new or replacement of permanent pacemaker have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion of a new or replacement of 
permanent pacemaker.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation procedure. 
 
You asked the Plan to pre-approve a lumbar facet joint radiofrequency ablation procedure. 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 facet joint interventions 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 a lumbar facet joint radiofrequency 
ablation procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the enrollee did not achieve greater than 80% pain relief. This should be interpreted as negative. The request is deemed as not medically reasonable or 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 a lumbar facet joint radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation 
procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational procedure whose role in managing knee pain is 
still being evaluated. Therefore, the request is considered not medically reasonable or 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter replacement of the mitral valve. 
 
You asked the Plan to pre-approve transcatheter replacement of the mitral valve. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 transcatheter replacement of the mitral 
valve. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation is inadequate to confirm fulfillment of 
published CMS guidelines for transcatheter mitral valve replacement (TMVR). As a result, at this time TMVR 
would not be considered medically reasonable and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter replacement of the mitral valve have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transcatheter replacement of the mitral valve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 18, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 office visit provided on November 18, 2021 by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost High Calorie Very Vanilla. 
 
You asked the Plan to pre-approve Boost High Calorie Very Vanilla. 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 does not pay for nutritional supplementation. 
 
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 Boost High Calorie Very Vanilla.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided December 21, 2021. 
 
You asked the Plan to pay for the dental consultation. You say that you would like your remaining dental 
allowance applied to this claim. The Plan denied your request. The Plan says this service is not covered under 
your benefits. 
 
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 pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint nerve ablations of cervical 
discs. 
 
You asked the Plan to pre-approve paravertebral facet joint nerve ablations of cervical discs. 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 the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and 
necessary 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 paravertebral facet joint nerve ablations 
of cervical discs. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found this exceeds the utilization criteria of the LCD. The request is deemed not medically reasonable or 
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 paravertebral facet joint nerve ablations of cervical discs have not been met. 
Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint nerve ablations of 
cervical discs.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for no-transport ambulance services you received on November 
26, 2021. 
 
You asked the Plan to pay for the no-transport ambulance services. You say that you were at a casino, and 
someone bumped into you and hit your chest. You said that the security team called an ambulance to make sure 
you were ok.  You stated that you did not need an ambulance called, so you do not feel as though you should 
have to pay for this. The Plan denied your request. The Plan says ambulance services where no transport occurs 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 26, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for no-transport ambulance services you received on 
November 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 RFA to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental/investigational because of the wide 
variation in efficacy in the peer reviewed literature. Therefore, the request is considered not medically 
reasonable or 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 4 skilled nursing visits, 8 physical therapy visits, 7 occupational 
therapy visits, and 1 social service visit. 
 
You asked the Plan to pre-approve 4 skilled nursing visits, 8 physical therapy visits, 7 occupational therapy 
visits, and 1 social service visit. You say that the services are necessary. The Plan denied your request. The 
Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 4 skilled nursing visits, 8 physical 
therapy visits, 7 occupational therapy visits, and 1 social service visit. Our reviewer says that the services are 
medically necessary. Our physician reviewer found based on the medical records provided there is 
documentation that the home health aide services are reasonable and necessary to the treatment of the 
enrollees illness or injury by the skilled professional staff. The enrollee has documented needs with regard to 
personal care related to her skilled nursing and therapy needs due to her falls, injuries and recent surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 skilled nursing visits, 8 physical therapy visits, 7 occupational therapy visits, 
and 1 social service visit have been met. Therefore, we decided that the Plan has to pre-approve 4 skilled 
nursing visits, 8 physical therapy visits, 7 occupational therapy visits, and 1 social service visit.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transport provided on October 30, 
2021. 
 
You asked the Plan to pay for the emergency ambulance transport. You say that the emergency ambulance 
transport was medically necessary. The Plan denied your request. The Plan says the emergency ambulance 
transport was not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. 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 emergency ambulance transport. Our 
reviewer says that the emergency ambulance transport was not medically necessary. Our physician reviewer 
found based on the medical records provided there is no documentation that the enrollee's presenting symptoms 
meet prudent layperson criteria for emergency care. The enrollee reported migraine, arm pain and anxiety needing more lorazepam; she was ambulating and conversing normally, was in no distress with normal vital 
signs and a normal physical assessment. The provided documentation does not support that other means of 
transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated 
for this enrollee on October 30, 2021. The documentation does not support that the enrollee needed the 
expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can 
provide for safe transport on October 30, 2021. The documentation does not support that the ambulance 
transport on October 30, 2021, was medically reasonable and necessary 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 emergency ambulance transport have not been met. Therefore, we decided 
that the Plan does not have to pay for the emergency ambulance transport provided on October 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyrizi. 
 
You asked the Plan to pre-approve Skyrizi. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Skyrizi.  
 
Benefits for Skyrizi 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited problem-focused oral exam (D0140) provided 
December 27, 2021. 
 
You asked the Plan to pay for the problem-focused oral exam. You say that this was an emergency exam. The 
Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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. The Plan covers the problem-
focused oral exam once per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a problem-focused 
exam was previously covered on March 1, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the problem-focused oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the limited problem-focused oral exam (D0140) provided December 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. 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. Medicare rules say that oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Ondansetron.