Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis 
without contrast (74176). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis without contrast. You say that the 
requested service is medically necessary. The Plan denied your request. The Plan says that the enrollee does not 
meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT scan of the abdomen and pelvis 
without contrast. Our reviewer says that the service is medically reasonable and necessary. Our physician 
reviewer found the enrollee has prostate cancer with a Gleason score of 6. The rising Prostate-Specific Antigen 
(PSA) test scores indicate the progression of the disease. Services including a CT scan are medically reasonable 
when there is clinical progression of the disease. 
 
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 CT scan of the abdomen and pelvis without contrast have been met. 
Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis without contrast (74176).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a medication called Tezspire (J2356). 
 
You asked the Plan to pre-approve a medication called Tezspire. You say that the enrollee has severe persistent 
life-long asthma with pertinent history of exacerbation, steroid dependence, and eosinophilia. The enrollee is 
experiencing dermatologic SE from Dupixent and the formation of eczema plaques at her Dupixent injection 
sites, placing her at risk for inadequate deposition of the medication, altered therapeutic effect, acute airway 
inflammation, and acute asthma exacerbation. The Plan denied your request. The Plan says that the request 
does not meet the Medicare or health plan coverage criteria. 
 
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 a medication called Tezspire. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has severe 
persistent asthma. Prior to 2020, she was having frequent exacerbations, uncontrolled symptoms, and was 
requiring systemic steroids. She started Dupixent in 2020 and improved significantly. However, she is 
experiencing skin rashes/plaques at the injection sites. It is reasonable to try switching from Dupixent to 
Tezspire, to try to maintain the improvement in asthma control without the skin issues caused by Dupixent. It is 
not reasonable to stop the Dupixent and wait until the enrollee again becomes uncontrolled and/or requiring 
systemic steroids, in order to meet the treatment requirements indicated by the Plan. 
 
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 medication called Tezspire have been met. Therefore, we decided that the 
Plan has to pre-approve a medication called Tezspire (J2356).  
 
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 a power wheelchair. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a past medical history of chronic obstructive pulmonary disease (COPD) 
and mobility impairments. There is no specific clinical documentation to describe mobility status or mobility 
device evaluation. Specifically, there is no information that the enrollee would not be able to use a manual 
wheelchair or walker. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair.
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 enrollee desperately needs acute care for 
activities of daily living (ADLs). The Plan denied your request. The Plan says the IRF admission is not 
medically necessary. 
 
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 provided documentation does not indicate that you have complex nursing or 
rehabilitation needs. The reviewer found that while you have a need for therapy, there is no documentation of a 
need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the requested IRF admission 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 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 pay for supplies for a continuous positive airway pressure (CPAP) 
device provided on December 9, 2021. 
 
You asked the Plan to pay for CPAP supplies. You say that the supplies at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery the supplies provided in this case. The documents 
provided as proof of delivery in this case apply to other dates of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for supplies for a continuous positive airway pressure (CPAP) device provided on 
December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care supplies to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve would care supplies. You say that you are appealing the denied wound care 
supply out of medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
provider is an OON provider and there are multiple in-network providers who can supply the enrollee with the 
requested supplies. 
 
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 
wound care supplies to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
requesting an appeal regarding the denial of coverage for the Flexitouch pneumatic compression pump 
prescribed to treat lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the 
LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
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 segmental pneumatic appliances (E0667, E0656).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 You asked the Plan to pre-approve facet joint injections. You say that the facet joint injections are medically 
necessary. The Plan denied your request. The Plan says facet joint injections are not medically necessary and 
do 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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that the LCD  criteria 
requires 80% pain relief from diagnostic blocks and at least 50% pain relief from therapeutic blocks with 
sustained pain relief. This threshold was not reached and therefore, the request is deemed not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
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 a Group 2 PWC 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 criteria for coverage are not met. Our physician reviewer found there is no documentation stating that the 
requested PWC is to be used in the home, what types of mobility-related self care tasks the enrollee is unable to 
accomplish, and that she can safely use the device. There is no documentation that she has had a specialty 
evaluation by a physical or occupational therapist. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulator, pulse generator, any 
type (L8679) and a percutaneous implantation of neurostimulator electrode array; peripheral nerve (64555). 
 
You asked the Plan to pre-approve an implantable neurostimulator. You say that the requested device is to help 
with your chronic pain/neuropathy and reduce the use of narcotics. The Plan denied your request. The Plan says 
the requested procedures are insufficient to warrant the medical necessity of coverage for PNS or PNFS, for 
any condition. 
 
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 an implantable neurostimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found medication trial have included Tylenol, Tizanidine, and Lyrica. Injection 
therapy has included lumbar ESI L5-S1, lumbar TF/SNRB; lumbar ESI L5-S1. There is insufficient support for 
this therapy for low back pain. 
 
 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 implantable neurostimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an implantable neurostimulator, pulse generator, any type (L8679) and a 
percutaneous implantation of neurostimulator electrode array; peripheral nerve (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral nutritional product. 
 
You asked the Plan to pre-approve oral nutritional product. You say that you would like the plan to reconsider 
their denial The Plan denied your request. The Plan says you do not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that orally administered enteral nutrition products are 
not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the items requested are for oral use. 
These items are specifically not covered. Based on this information, we decided that Medicare rules for 
coverage of oral nutritional product have not been met. Therefore, we decided that the Plan does not have to 
pre-approve oral nutritional product.
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 this admission is necessary for the 
enrollee. The Plan denied your request. The Plan says the medical criteria for an LTACH admission have not 
been met. 
 
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 all medically necessary care is being provided in the current acute care setting. 
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you just had a total knee replacement and cannot 
walk. You state you are not in any position to be by yourself. The Plan denied your request. The Plan says that 
the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our physician reviewer 
found daily skilled therapy is being recommended which seems reasonable as you have multiple weight bearing 
joints affected by arthritis. From a practical standpoint, daily skilled services in a SNF is 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cochlear implantation services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee will not be able to hear 
without the implants. The Plan denied your request. The Plan says the criteria for proceeding to cochlear 
implantation is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that cochlear implantation is only covered under 
certain indications.  
 
We looked at the file and Medicare rules. The records do not indicate that the enrollee is part of an approved 
clinical trial. 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 pre-approve cochlear implantation 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 requires daily labs, daily 
physician visits, and treatment plan medication management and monitoring. You state the enrollee will fail at 
lower level of care. The Plan denied your request. The Plan says the stay is not medically necessary based on 
LTACH criteria. 
 
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 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 health plan. The health plan has approved ongoing care 
in the current acute care setting. 
 
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.