Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the chiropractic services provided on April 
15, 2021, through November 29, 2021. 
 
You asked the Plan to waive the deductible for the chiropractic services. You say that the service should be 
covered. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to chiropractic services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category chiropractic 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time the chiropractic services were received on April 15, 2021, to November 29, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for the chiropractic services provided on April 15, 
2021, through November 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric admission from May 31, 2022 
forward. 
 
You asked the Plan to pre-approve an inpatient psychiatric admission. The Plan denied your request. The Plan 
says the request is not medically necessary because the records received show your condition has improved to 
where you now have more custodial needs. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
  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 inpatient psychiatric admission. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care from 
May 31, 2022 forward. Our physician reviewer found it is not expected this enrollee would improve in a 
reasonable period of time as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. Our reviewer 
also found that it does not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower 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 an inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an inpatient psychiatric admission from May 31, 2022 forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC). 
 You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare does not cover duplicate or redundant durable medical equipment such as 
oxygen device when the second item performs the same function as the one currently provided to the enrollee. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you have 
heart failure and chronic obstructive pulmonary disease, and are on home oxygen. You have a portable oxygen 
system, but say that you cannot carry it. Medicare requires testing during activity using an oxygen conserving 
device, and this has not been done.  Additionally, there is no documentation in the medical record of need for a 
POC. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator (POC).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by 
Medicare. 
 
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 requested services are not considered medically reasonable and necessary in this case. Documentation is 
lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as 
being the overwhelming primary generators of the enrollees chronic persistent pain. In this case, there are 
multiple plausible pathologic sources of significant pain generation. Documentation does not support actual 
formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable 
at this time. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
these services. 
 
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 the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair, group 2 standard, captains chair, 
patient weight capacity up to and including 300 pounds (K0823) Wheelchair component or accessory, not 
otherwise specified (K0108). 
 
 
You asked the Plan to pre-approve the power wheelchair. You say that the enrollee requires the wheelchair to 
get around. The Plan denied your request. The Plan says the records do not support that the requested power 
wheelchair and unspecified accessories is medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that this enrollee 
has a personal mobility deficit that impairs participation in mobility related activities of daily living such as 
toileting, feeding, grooming and bathing in customary locations within the home. Based on the medical records 
provided there is no documentation that the enrollee's mobility deficit cannot be helped by the use of a walker, 
cane or manual wheelchair. Based on the medical records provided there is no documentation that the patient 
can safely operate a power mobility device. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the power wheelchair, group 2 standard, captains chair, patient weight capacity 
up to and including 300 pounds (K0823) Wheelchair component or accessory, not otherwise specified (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1845). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item 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 knee orthosis. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document recent injury to the knee or knee surgery; records do not 
document objective findings of ligamentous laxity on physical examination of the enrollee's knees. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1845).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is experimental. 
 
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 requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is experimental and more research is needed to show its safety and 
efficacy. 
 
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 (64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your condition is not 
complex. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for weakness and a fall. Your medical problems are stable. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone/APAP for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is 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 pre-approve Oxycodone/APAP for the 
enrollee.  
 Benefits for this drug 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Mohs micrographic technique (17311) provided on July 20, 
2021. 
 
You asked the Plan to pay for a Mohs micrographic technique. You say that you have provided records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not allow separate payment for an 
additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior 
procedure and if billed without modifier 58, 78, or 79.  
 We looked at the file and Medicare rules. In this case, the record shows that the service at issue was provided 
during the postoperative period of a prior procedure. The service at issue was billed without the appropriate 
modifier. Based on this information, we decided that Medicare rules for coverage of a Mohs micrographic 
technique have not been met. Therefore, we decided that the Plan does not have to pay for a Mohs 
micrographic technique (17311) provided on July 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156) and skilled 
nursing services (G0299). 
 
You asked the Plan to pre-approve HHA and skilled nursing services. The Plan denied your request. The Plan 
says the HHA service is limited to members that require a skilled level of care and your needs can be met with 
a less complex service. The Plan also says that the requested service does not appear medically necessary. 
 
  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 HHA and skilled nursing services. Our 
reviewer says that HHA and skilled nursing services are not medically reasonable and necessary. Our physician 
reviewer found there is no documentation that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HHA and skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health aide (HHA) services (G0156) and skilled nursing 
services (G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care 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 that the patient was admitted for cellulitis and gangrene and had amputation of the great toe. The patient has been transferred to skilled nursing. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
patient has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and a portable gaseous oxygen 
system. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a qualifying blood gas study was not received. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 services are not medically reasonable or necessary. Our physician reviewer found that recent resting 
SpO2 readings are 95 to 97% on room air.  There is no oximetry with activity. There is no polysomnogram or 
evidence that obstructive sleep apnea is being treated. 
 
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 an oxygen concentrator and a portable gaseous oxygen system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick catheter system (K1006). 
 
You asked the Plan to pre-approve a PureWick catheter system. You say that you currently have a home system 
which is deemed medically necessary by your primary provider. You are requesting an authorization for 90 
days. The Plan denied your request. The Plan says the requested item is not a covered benefit under your Plan. 
The Plan also says you previously purchased the requested item out of pocket. 
 
While a catheter system may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a PureWick catheter system (K1006).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says the drug is not being 
prescribed for a medically accepted indication. 
 
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 Neulasta. Our physician reviewer found 
that the requested use of Neulasta is not FDA-approved for the enrollee's diagnosis. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
use is not listed as not indicated, not supported or not recommended in any of the compendia. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.