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

 
We decided that the Plan does not have to pre-approve a fixed height hospital bed (E0250). 
 
You asked the Plan to pre-approve a fixed height hospital bed. You say that this authorization should have been 
done through your lung doctor, not your gastrointestinal doctor. You also say that you only have one lung and 
chronic obstructive pulmonary disease (COPD), and with these conditions you should have been approved. The 
Plan denied your request. The Plan says the Medicare criteria has not been met. The Plan also says your request 
does not address the elements of the coverage criteria of the requested hospital bed because recent clinical 
documentation and orders were not received. 
 
The Plan follows Medicare rules. Medicare rules say that a fixed height hospital bed is covered if one or more 
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 a fixed height hospital bed. Our 
reviewer says that you do not meet the coverage criteria for a fixed height hospital bed. Our physician reviewer 
found there is no clinical documentation indicating you require the head of bed to elevated due respiratory or 
cardiovascular issues. You are noted to have gastroesophageal reflux disease, but it is not noted why 
positioning with an ordinary bed would not suffice, such as using a positioning pillow. Our reviewer found that 
you do not need frequent re-positioning while in bed and you are independent with bed mobility. Our physician 
reviewer found that therefore, the requested fixed height hospital bed (E0250) is not 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 a fixed height hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a fixed height hospital bed (E0250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
ventilator (E0466).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro (J2506). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee's white blood count (WBC) is low 
which can be extremely dangerous for the enrollee. You state that if the enrollee does not receive this 
medication that it could become dangerous to the enrollee's health as their WBC keeps dropping. The Plan 
denied your request. The Plan says the records provided do not indicate the enrollee cannot take the preferred 
medications of Fulphila and Ziextenzo for the enrollee's low neutrophils. The Plan states there is no documentation that the enrollee has failed the preferred products nor that the preferred products would cause 
adverse. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Fulphila and Ziextenzo, before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided 
indicating that the Plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Neulasta Onpro (J2506).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that this is medically necessary. The 
Plan denied your request. The Plan says a continuous glucose monitor is not covered under Medicare if the 
enrollee is not on insulin. 
 
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. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chest x-ray (71046) to be performed at a tertiary 
care facility. 
 
You asked the Plan to pre-approve the tertiary level of care. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the records do not state medical reasons why a chest x-ray needs 
to be done at a highly specialized tertiary care facility, nor why a chest x-ray cannot be done at an available in-
network imaging 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 tertiary level of care. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the requested chest x-ray is not medically necessary to 
be performed at a tertiary care facility. The x-ray can be performed at a Plan in-network imaging provider. 
 
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 tertiary level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the chest x-ray (71046) to be performed at a tertiary care facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is necessary. The Plan denied 
your request. The Plan says this is not covered by Medicare for any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that this is necessary for the 
enrollee. The Plan denied your request. The Plan says this is not necessary as the records do not show the 
enrollee requires treatment with three or more insulin injection a day. 
 
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. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device with associated leg 
sleeves (E0651 and E0669), to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device with associated leg sleeves. You say that 
the item is medically necessary. The Plan denied your request. The Plan says there are in-network provider(s) 
within a reasonable distance from the members location that can provide this service or item. 
 
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 
a pneumatic compression device with associated leg sleeves (E0651 and E0669), to be provided by an out-of-
network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 2, 2022, to 
August 19, 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 a correct bill type. 
 
The Plan follows Medicare rules. The rules say that home health service claims must be submitted with a 
correct bill type.  
 
We reviewed the file and the Medicare rules. We find that the claim was not billed with a valid bill type 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 August 2, 2022, to August 19, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that Orencia is preferable for the enrollee. The Plan 
denied your request. The Plan says the Plan requires a trial of Inflectra, Remicade, or Simponi Aria before it 
will approve Orencia. 
 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 Orencia. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Orencia. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Inflectra, Remicade, or Simponi Aria. The record 
does not support that these drugs would likely be less effective and/or 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 Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Orencia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that you want the Plan to approve 
this. The Plan denied your request. The Plan says a continuous glucose monitor is not covered under Medicare 
if the enrollee is not on insulin. 
 
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. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
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 you are stable and are ready to be 
transferred to an LTACH. You say that your needs cannot be adequately cared for with your current condition 
at a skilled nursing facility. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and you can get the care you need in another setting. 
 
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 you are improving but are still unstable and only requires short-term acute care at the 
current facility until you are more stable. You do not require services at the LTACH that are not already 
available at the current facility. 
 
   
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says the records do not show that the enrollee failed to 
improve despite non-surgical treatment. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation is lacking regarding reasonable detailed findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollee's chronic persistent 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 Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940 x 5) and the 
office visit (99203) provided from July 11, 2022, through August 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
services provided. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 these services. Our reviewer says that you do 
not meet criteria for coverage of the services provided. Our physician reviewer found that in this case, the 
record indicates that you have occipital headache and myofascial pain. The records provided do not document 
treatment for a subluxation of the spine. The elements of the coverage criteria are not satisfied. Additionally, 
the chiropractic office visit provided is not a covered benefit by Medicare or the Plan. We looked at this physician's review, the file, and both Medicare and the Plans rules. Based on this 
information, we decided that the rules for coverage of these services have not been met. Therefore, we decided 
that the Plan does not have to pay for the chiropractic manipulative treatments (98940 x 5) and the office visit 
(99203) provided from July 11, 2022, through August 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from March 17, 2022, to 
April 11, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that  The 
Plan denied your request. The Plan says the records do not support diagnosis code G93.41. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code G93.41, defined as metabolic encephalopathy. 
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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the documentation does not support diagnosis code G93.41. Our 
physician reviewer found there was no clinical or laboratory evidence of metabolic encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from March 17, 2022, to April 11, 2022, at the DRG originally billed.