Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration because 
the requested ventilator is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the requested BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found you have COPD and idiopathic 
pulmonary fibrosis. No pulmonary function tests are provided.  Arterial Blood Gas was done as an outpatient 
shows a normal measured the partial pressure of carbon dioxide in arterial blood. There is thus no need for a 
respiratory support device during sleep.  Medicare does not cover a ventilator when used as BiPAP.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator.
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 you would like reconsideration because the IRF 
admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage of the IRF services. 
 
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 enrollee is medically stable and does not need Physical Medicine and 
Rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No rehab nursing needs are identified or 
documented in the record. At the current functional level, the enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyrizi (J3590). 
 
You asked the Plan to pre-approve Skyrizi. You say that the enrollee has been on this medication since May 
2021 without flare ups. The Plan denied your request. The Plan says medication supplied from a pharmacy is 
not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Skyrizi (J3590).  
 
Benefits for Skyrizi 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 Transmitter continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee was previously using Freestyle Libre. 
You say that it is not covered by their insurance, but Dexcom is. You also say that Dexcom is medically 
indicated for glucose monitoring. The Plan denied your request. The Plan says the criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, nor has the enrollee had an in-person visit with their treating physician to 
assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided 
that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Dexcom G6 Transmitter continuous glucose monitor (CGM).
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 LTACH is the best place for the patient 
to receive the aggressive treatment needed for a quicker recovery. The Plan denied your request. The Plan says 
the patient is receiving appropriate care at their current acute facility. 
 
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 patient appears to be stable and improving and should only require short-term 
additional acute care services that can be safely completed at the current location until appropriate for transfer 
to a lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Transfer to a lower level of care may be considered when treatment is completed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network office visits with a tertiary level of care 
Interventional Radiologist and echocardiogram. 
 
You asked the Plan to pre-approve the out-of-network, tertiary level of care office visits and echocardiogram.. 
You say that you would like reconsideration because the requested services are medically necessary. The Plan 
denied your request. The Plan says the records do not describe a medical problem that needs to be managed or 
treated by a tertiary care provider.  
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 out-of-network, tertiary level of 
care office visits and echocardiogram.. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there are credentialed, 
experienced physicians within the patients network who could be utilized for the patient's clinical condition. In 
summary, there is insufficient documentation to support the medical necessity for referral to an out-of-network 
provider for the patients management. 
 
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 out-of-network, tertiary level of care office visits and echocardiogram. have 
not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-network office visits 
with a tertiary level of care Interventional Radiologist and echocardiogram.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided 
August 27, 2021. 
 
You asked the Plan to pay for the pathology procedure. You say that the test was requested directly from the 
treating physician who makes the professional determination of diagnosis and medical necessity to successfully 
treat the enrollee. The Plan denied your request. The Plan says the services do not meet coverage requirements. 
 
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 pay for the pathology procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found given the lack of validation of the models/algorithms in independent publications, the 
unclear behavior in other screened populations, and the lack of clarity regarding the incremental value and cost 
effectiveness of this assay, the panel cannot recommend the routine use of this test at this time. Longer term 
follow-up of the cohorts to determine whether missed prostate cancers were ultimately detected is needed. In 
addition, validation of these tests in other cohorts of men is needed before they can be accepted as alternatives 
to (or perhaps preferable to) other tests. The NCCN Panel considers SelectMDx to be investigational at the 
present time. There is no direct evidence that supports the clinical utility of the test, and the chain of evidence 
is incomplete due to the limitations in clinical validity and clinical utility. The evidence is insufficient to 
determine the effects of the technology on health outcomes. 
 
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 pathology procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for unlisted molecular pathology procedure (81479) provided August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evaluation of the home to see if it is able to accommodate the 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.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that you have a mobility deficit that impairs MRADLs in the home. There is no evidence that 
you could not use a walker, cane, or manual wheelchair. The documentation does not reveal a home assessment 
to support that the requested device will able to safely maneuver in the home and access rooms. The 
documentation does not support that this scooter will significantly improve your ability to participate in MRADLs, and that you will use it in the home. You are able to walk 50 yards, and have normal upper body 
strength and coordination. Therefore, it is unclear why can't use a walker or manual wheelchair. The 
documentation does not reveal that the requested K0800 motorized scooter 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 the scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was no longer enrolled in 
hospice on the date of service in this case. The Plan denied your request. The Plan says the claim denied 
correctly. 
 
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 laboratory services provided on November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular electrical stimulator provided on June 24, 
2021. 
 
You asked the Plan to pay for the provided services. You say that the service was appropriate based on the 
enrollee's condition and clinical assessment. The Plan denied your request. The Plan says this is not a Medicare 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that neuromuscular electrical stimulation is only 
covered under certain medical indications.  
 
 We looked at the file and Medicare rules. The medical records show that the enrollee is being treated for a 
meniscus tear and medial tibial fracture. The records do not indicate that she is being treated for disuse atrophy. 
The records also do not show that the electrical stimulation is part of the physicians treatment plan for the 
enrollees condition. Based on this information, we decided that Medicare rules for coverage of the provided 
services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
electrical stimulator provided on June 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition.  The enrollees care needs, 
custodial and intermittent, can, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bi-level positive airway pressure (BiPAP) device 
provided on September 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the BiPAP device. You say that you needed a new machine due to a recall. The 
Plan denied your request. The Plan says the provider is not certified by Medicare. 
 
 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 provider in this case is not a network provider with the Plan. The provider is also not an approved 
Medicare provider. The Plan had network providers available who could have provided the items at issue in 
this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan 
to pay for this item. Therefore, we decided that the Plan does not have to pay for the bi-level positive airway 
pressure (BiPAP) device provided on September 30, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 laboratory services provided on December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro2 Motion 2 orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase  participation in 
bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro2 Motion 2 orthotic device for the enrollee.
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 you believe the enrollee is stable and 
will be best managed at the LTACH at this time. You also say that an LTACH is the medically appropriate 
admission for this enrollee. The Plan denied your request. The Plan says your request for approval of an 
LTACH admission does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be unstable and not improving with current treatment and 
requires short-term additional acute care services that can be safely completed at the current location until 
appropriate and stable for transfer. Our reviewer found that there are no services at the LTACH that the patient 
requires that are not already available and covered at the current acute care facility. Our physician reviewer also 
found that a transfer to an LTACH is not medically necessary as it would not be clinically advantageous at this 
time. Transfer may be considered when treatment is completed and the patient is more stable.  
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.