Persius/hicric huggingface dataset:
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 have fallen and broke your hip. You also say 
you are requesting acute rehabilitation to regain your full mobility and proper care. The Plan denied your 
request. The Plan says based on Medicare guidelines the inpatient rehabilitation facility services you are 
requesting do not meet the requirements for approval. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lymphedema clinic evaluation/therapy. 
 
You asked the Plan to pre-approve a lymphedema clinic evaluation/therapy. The Plan denied your request. The 
Plan says there is no diagnosis of lymphedema. The Plan also says the enrollee has a history of right foot 
osteomyelitis from chronic diabetic foot ulcer, but there is no clear diagnosis justifying this request. 
 
The Plan follows Medicare rules. Medicare rules say that the coverage of CDP therapy would only be allowed 
if all of the conditions listed in the Medicare rules section of this letter have been 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 lymphedema clinic 
evaluation/therapy. Our reviewer says that the enrollee does not meet the criteria for coverage for a 
lymphedema clinic evaluation/therapy. Our physician reviewer found the documentation is insufficient and 
does not support the need for lymphedema treatment by a physical therapist because it is lacking the diagnosis 
and is not medically necessary for coverage. Our reviewer found that lymphoedema clinic treatment is not 
medically necessary for a chronic condition such as cellulitis in the enrollee with diabetes mellitus and 
neuropathy with Charcot's joint. Our physician reviewer also found that this request is not reasonable based on 
lack of the physician's documentation of the diagnosis. 
 
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 lymphedema clinic evaluation/therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lymphedema clinic evaluation/therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mvasi. 
 
You asked the Plan to pre-approve Mvasi. 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 pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Mvasi. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Bevacizumab (Mvasi) is not FDA 
approved as monotherapy for recurrent metastatic colon cancer. Use is not supported by major drug compendia, 
the NCCN Guidelines, or major drug compendia as monotherapy. The service is not reasonable or 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 Mvasi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Mvasi.
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 it is medically necessary for you to get this service in 
order to lead your life as independent as you live by yourself. The Plan denied your request. The Plan says 
based on Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
back pain and sacral fractures. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. While the medical records support a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hormone therapy. 
 
You asked the Plan to pre-approve the hormone therapy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says there is physician order for this service. 
 
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 hormone therapy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the hormone treatment at issue in this case meets all Medicare 
criteria for medically reasonable and necessary and safe and effective for the patient. Provided records do not 
document that the patient's physician has recommended or ordered any hormone treatment. Records, in fact, 
document that estrogen, progesterone and testosterone have been discontinued and any over-the-counter 
hormone treatment is to be avoided.  
 
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 hormone therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the hormone therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of the intraosseous basivertebral 
nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral (Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are filing a re-review for wrongful 
denial for Intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. 
The Plan denied your request. The Plan says this procedure is considered experimental and investigational as 
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 looked at 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 thermal destruction of the intraosseous basivertebral nerve for the first 2 vertebral bodies with 
imaging guidance, lumbar or sacral (Intracept procedure) (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Inogen One portable oxygen concentrator. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the patient's portability needs are met; therefore, the request is not medically reasonable 
or necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 the criteria are 
not fully met. There is no testing to document that SpO2 can be maintained >91% during activity with flow rate 
1 to 4 L/min using an oxygen conserving device. This is required by Medicare. 
 
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 the Inogen One portable oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve Otezla. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says Otezla is not covered under the enrollee's Medicare Part B benefit. 
 
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 Otezla.  
 
Benefits for Otezla 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: 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 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 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your 
functional status. You can receive further services at 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 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 Novolog Flexpen. 
 
You asked the Plan to pre-approve Novolog Flexpen. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Novolog Flexpen to be administered at home without a 
subcutaneous insulin pump is not covered under Medicare 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 Novolog Flexpen.  
 
Benefits for Novolog Flexpen 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 pre-approve a mandibular partial denture - flexible base (D5226). 
 
You asked the Plan to pre-approve the mandibular partial denture - flexible base (D5226). You say that you are 
requesting reconsideration stating you have very few teeth left due to a childhood disease and lack of medical 
treatment. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 pre-approve a 
mandibular partial denture - flexible base (D5226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that you would like to be able to be independent 
and take care of yourself as much as you can without being a burden to others unless necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for a power scooter. 
 
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.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair and you cannot 
safely operate the PMD being requested. Specifically, the enrollee is ambulatory, and their mobility limitations 
can be safely resolved with a cane. The enrollees home is too cluttered to safely use PMD and the enrollee has 
expressed unwillingness to use PMD within the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve the power operated 
vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge management services provided on March 29, 
2022, billed with code 99239. 
 
You asked the Plan to pay for the discharge management services. You say that the services billed should be 
paid. The Plan denied your request. The Plan says code 99239 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is Hospital discharge day management; more than 
30 minutes.  

We find that CPT code 99239 is not supported in the medical record. Specifically, the records submitted do not 
include a discharge progress note documenting that 31 or more minutes were spent. The records included a 
discharge note from a prior admission only. Based on this information, we decided that Medicare rules for 
coverage of the discharge management services have not been met. Therefore, we decided that the Plan does 
not have to pay for the discharge management services provided on March 29, 2022, billed with code 99239.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on February 24, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the non-emergency procedure code was billed correctly. You also say that you would like this claim to be 
reviewed and processed towards payment. The Plan denied your request. The Plan says non-emergency 
ambulance transportation is covered when it is the only way to safely and adequately transport an enrollee, or if 
other means of transporting an enrollee are unsafe due to a medical condition. The Plan also says this claim 
does not meet these requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation via ambulance from the hospital to the 
enrollees residential facility was not medically necessary. Our physician reviewer found the enrollee did not 
require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Our reviewer found that transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollees condition. Our physician 
reviewer also found that a prudent layperson would not believe that immediate medical attention was required 
for someone who was being discharged from the hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on February 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Gel-One. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of unilateral primary osteoarthritis of the left knee. The documentation does 
not support that the enrollee has tried and failed Durolane, Euflexxa, Supartz, or Gelsyn-3. The documentation 
does not support that Durolane, Euflexxa, Supartz, or Gelsyn-3 would likely be less effective and/or likely have 
adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.