Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the trips are necessary. 
The Plan denied your request. The Plan says the request exceeds the maximum count allowed per period. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage.  
 
We looked at your request, the records in the case file, and the rules. The 61st trip and beyond is not a covered 
benefit. Your 2022 EOC states up to 60 one-way trips are covered each year (limited to ground transportation 
only). Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supply allowance provided 
on December 20, 2021. 
 
You asked the Plan to pay for the continuous glucose monitor supply allowance. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for this 
date of service.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the continuous glucose monitor supply allowance provided 
on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and 
the other requested accessories. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the notes do not show that the enrollee has a medical need for these power options. The 
Plan states upgraded electronics (expandable controller, harness and electronics) cannot be covered per 
Medicare rules. The Plan states there is not a medical need to control more than two power options though the 
joystick. 
 
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 DME. Our physician reviewer 
found there is no documentation that the group 3 power wheelchair with multiple power option (power tilt and power recline) at issue in this case meets Medicare criteria for medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient 
weight capacity up to and including 300 pounds (CPT code K0861) and the other requested accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Incruse Ellipta. 
 
You asked the Plan to pre-approve Incruse Ellipta. 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 Incruse Ellipta.  
 
Benefits for Incruse Ellipta 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 a cervical epidural injection. 
 
You asked the Plan to pre-approve a cervical epidural injection. You say that a cervical epidural injection is 
medically necessary. The Plan denied your request. The Plan says the requested cervical epidural injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve a cervical epidural injection. Our 
reviewer says that a cervical epidural injection is not medically necessary. Our physician reviewer found in this 
case, there is no documentation of 50% pain relief for 3 months, or the use of a different approach, level, and/or 
medication used for the 2nd cervical epidural injection.  The review has determined that the requested cervical 
ESI is 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 cervical epidural injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cervical epidural injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 14, 2022, to 
February 8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the NOA must be submitted to Medicare by the 
home health agency. 
 
We looked at the file and Medicare rules. The file shows that the required NOA was not submitted for this 
claim. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
January 14, 2022, to February 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that the enrollee has multiple risk factors for delays in 
treatment. The Plan denied your request. The Plan says the use of granulocyte colony-stimulating factor for the 
prevention of febrile neutropenia would not be recommended. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Fulphila. Our physician reviewer found 
that the enrollee has metastatic breast cancer being treated with Enhertu. Her absolute neutrophil count as of 
was 3500/mcL. Treatment with Fulphila injections has been requested for febrile neutropenia prophylaxis. The 
requested use of Fulphila is not FDA approved for the enrollee's diagnosis. The use of Fulphila in this case is 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. The use of Fulphila in this case does not meet Medicare criteria for 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 Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the surgery is necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of chronic low back pain have not been demonstrated in the peer-reviewed literature. The Plan states that more 
research is needed to show safety and efficacy of the procedure. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept remains 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 (CPT code 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and related accessories and features. 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair. You say that the requested power 
wheelchair is a medical necessity for the enrollee who no longer resides in a skilled nursing facility or hospital. 
The Plan denied your request. The Plan says rules for coverage for durable medical equipment have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
In this case, the Plan indicates that a Group 3 standard power wheelchair is being requested for use in a SNF or 
hospital. There is insufficient documentation in the case record to contradict the Plan's statement. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and related accessories and features.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says medical records were 
not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services provided on January 
21, 2022. have been met. Medical records were not submitted by the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiological services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve radiological services. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
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 
radiological services to be provided by an OON provider.
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 clearly exceeds the Centers 
for Medicare & Medicaid Services (CMS) established defining criteria for an appropriate LTACH admission. 
The Plan denied your request. The Plan says the records do not show that the enrollee needs daily doctor visits 
or more than six hours of nursing care each day. The Plan also says the records do not show that the enrollee 
needs a machine to help them breath, or complex medicine. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. Our reviewer also found that 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 Orthovisc. 
 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 Orthovisc is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. The 
records do not document that she has tried and failed at least three months of conservative therapy. The criteria 
for coverage are not met and the Orthovisc is therefore 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 Orthovisc.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimbursement for the destruction of premalignant lesions, 15 or more lesions, 
(17004) provided on March 10, 2022. 
 
You asked the Plan to reimbursement for the surgical service. You say that you should be reimbursed for this 
service. The Plan denied your request. The Plan says that dermatology services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not supported the reason for denial of this service. 
Therefore, we decided that the Plan has to reimbursement for the destruction of premalignant lesions, 15 or 
more lesions, (17004) provided on March 10, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission. 
 
You asked the Plan to pre-approve an inpatient admission. You say that you will not be able to properly care 
for yourself after receiving the surgery. You also say that you need to undergo observation to ensure there are 
no complications. The Plan denied your request. The Plan says your care could be provided without an 
inpatient stay after your surgical procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
  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 admission. Our reviewer 
says that the documentation does not support that the criteria for an inpatient admission are met in this case. 
Our physician reviewer found you are having routine hip replacement surgery. This may safely be done with a 
48-hour observational stay. Our reviewer also found that an inpatient admission is not 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 an inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 17, 2020, to 
October 9, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like the records to be reviewed 
and the claim to be reprocessed and paid. The Plan denied your request. The Plan says services were rendered 
by an out-of-network provider and the services were not referred by a network provider. The services were not 
urgent or emergent, nor were they 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 home health services provided on August 17, 
2020, to October 9, 2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the surgery is necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of vertebrogenic low back pain and lumbar spondylosis without myelopathy or radiculopathy have not been 
demonstrated in the peer-reviewed literature. The Plan states that more research is needed to show safety and 
efficacy of the procedure. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found intracept 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 (CPT code(s): 64628 and 64629).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HH SN services (CPT code G0299 x 4). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee has not been taken to the emergency room or been admitted again to the 
hospital recently. The Plan states the enrollee does not have any wounds that require nursing care and there has 
been no report of swelling in their legs. The Plan states the enrollee's records do not support the need for a 
skilled nurse to make more visits. 
 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 the services. Our physician reviewer 
found the enrollee does not have documented, HH skilled nursing needs (i.e., IVs, complex wounds care, new 
ostomy, new TFs).  As such, the requested, ongoing, HH SN services are not medically necessary or 
reasonable. 
 
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 HH SN services (CPT code G0299 x 4).