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

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on October 19, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on October 
19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injectable drugs provided on October 25, 
2022, to October 27, 2022. 
 
You asked the Plan to waive the coinsurance for injectable drugs. You say that you were not told of any 
charges to be incurred for these drugs. Had you known about the charge, you would not have had the 
injections. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for injectable drugs. This item/service falls within the Medicare 
Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for injectable drugs provided 
on October 25, 2022, to October 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 31, 2021, 
to January 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that SNF services must be submitted with a Plan of Care. 
 
We reviewed the file and the Medicare rules. We find that the medical records submitted do not include a Plan 
of Care for the services rendered. Based on this information, we find that the Medicare rules for payment of the 
claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from December 31, 2021, to January 29, 2022.
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 need assistance with daily living activities and 
feel that the services will help you to regain full mobility. The Plan denied your request. The Plan says the 
services you need can be provided safely in another setting such as a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 
 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on October 26, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on October 
26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee will benefit from non-invasive 
ventilation at home as bilevel positive airway pressure (BiPAP) will not be adequate to ensure tidal volumes. 
The Plan denied your request. The Plan says a BiPAP device with average volume-assured pressure support 
(AVAPS) would meet all the needs requested by provider. 
 
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 chronic obstructive pulmonary disease (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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that in this case, the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease and presumed 
obstructive sleep apnea. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP 
machine with AVAPS capability. The Plan has indicated coverage for such a device is available upon request. 
The elements of the coverage criteria are not satisfied. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 10, 2022, 
to October 9, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the appropriate data 
elements. 
 
The Plan follows Medicare rules. The rules say that home health claims must be submitted with certain data 
elements.  
 
We reviewed the file and the Medicare rules. We find that the claim was billed with an invalid or missing FIPS 
85 value code with amount. Based on this information, we find that the Medicare rules for payment of the 
claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from September 10, 2022, to October 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue- based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (code 0627T). 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue- based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level. You say that 
percutaneous injection of allogeneic cellular and/or tissue- based product, intervertebral disc, unilateral or 
bilateral injection, with fluoroscopic guidance, lumbar; first level is medically necessary. The Plan denied your 
request. The Plan says percutaneous injection of allogeneic cellular and/or tissue- based product, intervertebral 
disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level is not medically necessary. 
 
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 percutaneous injection of allogeneic 
cellular and/or tissue- based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level. Our reviewer says that the requested percutaneous injection of allogeneic cellular 
and/or tissue- based product is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is an experimental/investigational procedure that is the subject of ongoing clinical 
trials. Therefore, the request is deemed not 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 percutaneous injection of allogeneic cellular and/or tissue- based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic 
cellular and/or tissue- based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level (code 0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a ventilator is medically necessary for 
management of life threatening chronic respiratory failure with hypercarbia and hypoxemia. The patient has 
previously failed BiPAP due to intolerance to a high-pressure requirement. The Plan denied your request. The 
Plan says a ventilator is not medically necessary. The patient had a Trilogy machine with noncompliance due to 
mask fitting and claustrophobia. No additional compliance data was provided. Without evidence of compliance 
with existing ventilator, continued use is not medically necessary. 
 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this male enrollee has chronic 
respiratory failure. He had a Trilogy machine with noncompliance due to mask fitting and claustrophobia. The 
record indicates that he was hospitalized for pneumonia with respiratory failure in February of 2023. On follow 
up from the hospital, he reported mask intolerance and some use of the device. Compliance data was not 
provided. The enrollee has a prescription for home ventilation from January 23, 2023, for exclusive use in 
average volume-assured pressure support (AVAPS), which is a mode available on bilevel positive airway 
pressure (BiPAP) devices. This patient does not have neuromuscular disease, thoracic restrictive disease, or 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. The documentation in the 
medical record does not support that the ventilator at issue is medically necessary and reasonable for this 
patient. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that you prescribed this medication due to a medical 
history of rheumatoid arthritis with active joint pain.  This medication has provided relief in the past. The Plan 
denied your request. The Plan says this drug is not covered under the patient's medical benefits. 
 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 Methotrexate.  
 
Benefits for Methotrexate 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that since being hospitalized, there has been a significant 
decrease in the enrollee's function, and you feel the enrollee will benefit from the services offered at the SNF. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for services in a SNF. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for migraine 
treatment. 
 
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 items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that you have a history of migraine 
headaches with reported 24 headache days per month with an average of one attack per day. You have had 
multiple admissions for migraines and have tried multiple medications. The records do not support that you 
require the inpatient level of care. You do not have significant neurological impairments or conditions such as a change in your mental status, a new or worsening neurological condition, altered level of consciousness, or 
significant changes in your speech. The inpatient admission is 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 an acute inpatient hospital admission for migraine treatment.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve diagnostic medial branch blocks (MBBs) (64493, 64494). 
 
You asked the Plan to pre-approve diagnostic MBBs. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the request is not medically 
necessary. 
 
The Plan follows Medicare rules. The rules say that facet joint interventions are medically reasonable and 
necessary for the diagnosis and treatment of chronic pain when all of the criteria listed in the Medicare rules 
section of this letter 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 diagnostic MBBs. Our reviewer says 
that the requested services are medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has symptoms and signs compatible with facet syndrome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic MBBs have been met. Therefore, we decided that the Plan has to 
pre-approve diagnostic MBBs (64493, 64494).  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee can continue to receive care at the current acute care hospital. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute hospital with Covid-19, pneumonia, and acute 
hypercapnic respiratory failure. The enrollee is receiving appropriate care at the present acute care hospital. 
The enrollee does not require services at the LTACH that are not available at the acute care hospital where he 
is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 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 pay for the office visit (99212), and pelvic and breast examination 
(G0101) provided on October 06, 2022. 
 
You asked the Plan to pay for the office visit (99212), and pelvic and breast examination (G0101). You say that 
the service should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99212), 
and pelvic and breast examination (G0101) provided on October 06, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infliximab. 
 
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 items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that you have a diagnosis of skin ulcers 
(pyoderma gangrenosum). The Infliximab is requested at a dose of greater than 5 mg/kg. The Medicare rules do 
not document that this is a diagnosis for which Infliximab is covered. 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 Infliximab.