Persius/hicric huggingface dataset:
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 you would like this item so 
you can travel. The Plan denied your request. The Plan says this item is not covered for travel. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator (E1392).
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 you would like this item to 
exercise and run errands. The Plan denied your request. The Plan says you already have similar equipment that 
meets your needs for inside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator (E1392).
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 you are requesting reconsideration for the denial of 
admission to an IRF. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 
not been met. 
 
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 clinical documentation does not show that you have active medical 
comorbidities or complex functional impairments; thus, the complexity of your documented nursing, medical 
and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation 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 pneumatic compression device (E0652) and sleeve 
(E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the beneficiary does not have lymphedema extending 
onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the 
chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and sleeve (E0668).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with SBRT. 
 
You asked the Plan to pre-approve SBRT. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational. 
 
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 SBRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the rules explicitly state that SBRT is not covered when the tumor burden cannot be completed targeted with acceptable risks to critical normal tissues. In other words, patients with widespread metastases, 
even if controlled, would not qualify under the rules. The rules also consider treatment of lesions of bone to 
not be medically necessary for SBRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with SBRT.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says that an IRF admission is not 
medically necessary, and the services the enrollee's needs can be provided safely in another setting. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollee has complex functional impairments and active comorbidities. While the enrollee would 
be expected to require inpatient hospitalization with an interdisciplinary approach to rehabilitation care, they 
can continue skilled therapy in an acute inpatient rehab. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 foot orthotics (L3400). 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3400).
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 enrollee meets the defining criteria 
for a medically appropriate LTACH admission. The Plan denied your request. The Plan says the enrollee may 
adequately receive the care needed in the current location, it is of no benefit to continue to move to other 
facilities for care. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving 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 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 specialist service to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist service. You say that you do not do the needed procedures, but 
this provider does. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and the enrollee can be treated within the Plan 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 
specialist service to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
You asked the Plan to pre-approve a flex foot system (L5980), vertical loading pylon (L5987), and below-knee 
flexible protective outer surface cover (L5962). You say that the enrollee's functional level is K3 or K4. The 
Plan says that there are no records to support that the enrollee is a K3 ambulator. 
 
We decided that the Plan has to pre-approve flex foot system and vertical loading pylon.  
 
The Plan follows Medicare rules. Medicare rules state that a flex foot system and shank foot system with 
vertical loading pylon may be covered for beneficiaries whose functional level is 3 or above.  
 
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 flex foot system and vertical loading 
pylon. Our reviewer says that the enrollee meets criteria for the requested flex foot system and vertical loading 
pylon. Our physician reviewer found the enrollee has a previous below-knee amputation. The prosthetic makes 
clear that the enrollee ambulates at a community level, walks extensively, and does not have a vehicle. These 
components are 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 lower limb prosthetic components have been met. Therefore, we decided that 
the Plan has to pre-approve flex foot system and vertical loading pylon.  
 
We also decided that the Plan does not have to pre-approve outer surface cover. 
 
The Plan follows Medicare rules. Medicare rules state that protective outer surface coverage are used by 
enrollees that have special needs for protection against unusually harsh environmental conditions.  
 
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 outer surface cover. Our reviewer says 
that the enrollee does not meet criteria for the outer surface cover. Our physician reviewer found the outer 
cover 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 outer surface cover have not been met. Therefore, we decided that the Plan does 
not have to pre-approve outer surface cover. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service January 8, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that the denial of 
payment is incorrect. The Plan denied your request. The Plan says the tests must be billed with modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, and 88381. This 
means there is both a professional and technical component for the codes. In this case, an appropriate modifier 
to indicate the professional component has not been billed with the codes. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 88341, 88342, 88360, and 88381 billed for date of service January 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Remicade (J1745). 
 
You asked the Plan to pre-approve Remicade. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug have not 
been met. 
 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 Remicade. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Inflectra or Renflexis before they will approve the requested drug. The requested drug is 
a new start. The provided records do not indicate that you have tried and failed the Plan's preferred step-one 
alternatives. The record does not indicate that you have a contraindication to, or would have an adverse effect 
from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Remicade (J1745).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says based on Medicare guidelines the long term acute care 
hospital services you are requesting do not meet the requirements for approval. 
 
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 is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital or skilled nursing facility where 
they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable but remains with 
strong LTACH criteria and requires that level of care. The Plan denied your request. The Plan says the 
requested LTACH services do not meet the requirements for approval. 
 
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 all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the request 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 Botox. Our reviewer says that the 
requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has migraine headaches. The record provided does not document the presence of the necessary 
diagnostic criteria for coverage of the requested drug to be available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 67228 billed for date of service August 30, 
2022. 
 You asked the Plan to pay for procedure code 67228. You say that the enrollee received bilateral services. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 67228 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. The records show that the Plan has paid 1 unit of code 67228. Therefore, we decided that the Plan 
does not have to further pay for procedure code 67228 billed for date of service August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty and kyphoplasty spine surgeries. 
 
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 vertebroplasty and kyphoplasty 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation in the 
submitted records of a trial and failure of recent, reasonable, comprehensive and less-invasive compression 
fractures at all of the requested surgical levels. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested procedure in this clinical setting. The requested procedures are not 
reasonable or medically necessary at this time. 
 
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 vertebroplasty and kyphoplasty spine surgeries.