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

 
We decided that the Plan does not have to pay for the x-ray of the swallowing function (74230) and x-ray of the 
upper gastrointestinal (GI) tract (74240) provided on August 31, 2022. 
 
You asked the Plan to pay for the x-rays of the swallowing function and upper GI tract. You say that you would 
like this claim to be reprocessed with supporting documentation. The Plan denied your request. The Plan says 
the documentation supports the studies represented by codes 74230 and 74240 were performed at a nursing 
home (by mobile van/portable x-ray) which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures involving fluoroscopy and procedures 
involving the use of contrast media are not covered under the portable x-ray provision. 
 
We looked at the file and Medicare rules. The services provided were for a barium swallow study in the 
portable mobile radiology setting. That imaging requires both the use of fluoroscopy and contrast. Based on 
this information, we decided that Medicare rules for coverage of the x-rays of the swallowing function and 
upper GI tract have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray of the 
swallowing function (74230) and x-ray of the upper gastrointestinal (GI) tract (74240) provided on August 31, 
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. The Plan denied your request. The Plan says the enrollee does not 
meet all the required criteria for admission to an Inpatient Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to ambulate without assistance as 
well as bear weight on your left shoulder. You say that you are losing function in your right leg and with 
rehabilitation you will be able to return to your full level of function. The Plan denied your request. The Plan 
says an IRF admission is not medically necessary, and you can safely receive the services you need in other 
settings. 
 
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 that you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as skilled nursing 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent Syringe. 
 
You asked the Plan to pre-approve Dupixent Syringe. You say that the enrollee has tried and failed other drugs. 
The Plan denied your request. The Plan says Medicare Part B is not responsible for self-administered drugs. 
 
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 Dupixent Syringe.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Eylea injection (J0178). 
 
You asked the Plan to pre-approve an Eylea injection. You say that Medicare has paid for Eylea injections 
since 2019 with no denial. You also say that without these injections periodically when the fluid in your eye 
builds, you would go blind in your right eye. The Plan denied your request. The Plan says medical studies have 
not proven that the drug is helpful for treatment of Retinal neovascularization, unspecified, right eye. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Eylea injection. Our reviewer says 
that an Eylea injection is not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of unspecified retinal neovascularization. The FDA 
has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation.  The elements of the coverage criteria are not satisfied. Our physician reviewer also 
found that 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 an Eylea injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Eylea injection (J0178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for date of service 
February 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that all charges should be processed as out-of-
network. The Plan denied your request. The Plan says the correct NPI was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The durable medical equipment was billed by a medical provider, which 
bills under the physician fee schedule. The equipment at issue is not eligible for payment under the physician 
fee schedule. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
billed for date of service February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee and an advanced foot with vertical shock. 
 
You asked the Plan to pre-approve the requested prostheses. You say that the enrollee was highly active prior 
to amputation. The Plan denied your request. The Plan says that the request exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses 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 prostheses. Our physician 
reviewer found that the enrollee has an above knee transfemoral amputation. The enrollee is a very active adult 
who lives in more than one environment. He lives in an area with steep inclines. The microprocessor knee is 
safer on steep inclines and requires less energy expenditure than other prostheses. Medicare authorizes a 
microprocessor knee for a level 3 ambulator, and the microprocessor has literature support for its use for an 
active adult who negotiates highly variable terrain. Therefore, the request 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 requested prostheses have been met. Therefore, we decided that the Plan has 
to pre-approve a microprocessor knee and an advanced foot with vertical shock.  
 
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 the Intracept intraosseous nerve ablation system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says there have been no specific studies done to identify that the basivertebral nerve is the 
cause of the pain. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this procedure is experimental. More research is needed. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept intraosseous nerve ablation system.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code A5063 billed for dates of service May 10, 2022, to May 
31, 2022. 
 
You asked the Plan to pay for the billed services. You say that the items can be billed together. The Plan denied 
your request. The Plan says that no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and the rules. The Plan denied the items under the physician fee schedule. However, the 
billing provider is a pharmacy, which is able to bill supplies under the durable medical equipment fee schedule. 
Based on this information, we decided that Medicare rules for coverage of the billed services have been met. 
Therefore, we decided that the Plan has to pay for procedure code A5063 billed for dates of service May 10, 
2022, to May 31, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve Trulicity. The Plan denied your request. The Plan says this drug is not 
covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.  
 
 
 Benefits for Trulicity 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673), provided 
on August 4, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items should be covered. The 
Plan denied your request. The Plan says a pneumatic compression device is not covered for the prevention of 
deep vein thrombosis during or after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675, E0673), provided on August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each wound care service provided on 
August 23, 2022, to October 10, 2022. 
 
You asked the Plan to reduce the copayment for each wound care service. You say that these wound care visits 
were necessary for surgery follow-up care. 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 a $325 
copayment for surgery or other services provided at an outpatient hospital. 
 
You have been asked to pay a $325 copayment for each wound care service. This item/service falls within the 
surgery or other services provided at an outpatient hospital 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. However, since the allowed amounts are less than 
the standard copayment, you only owe $186.23 for 10 claims and $191.35 for 2 claims. Therefore, we decided that the Plan does not have to reduce the copayment for each wound care service provided on August 23, 2022, 
to October 10, 2022.
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 enrollee clearly exceeds the criteria 
for an appropriate Long Term Acute Care Hospital admission. The Plan denied your request. The Plan says the 
records do not show the continued treatments and care can only be given in a hospital setting, it is unclear that 
the enrollee's condition will require an average 25-day length of stay in the LTACH, medically necessary care 
may be provided safely in a different level of care. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
(87500, 87641, 87653) provided on February 10, 2022. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the urine PCR panel 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase 
chain reaction (PCR) panel testing (87500, 87641, 87653) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-ray (D0210, 
D0150) provided on November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation and intraoral x-ray (D0210, D0150) provided on November 17, 
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 item is medically necessary. The Plan 
denied your request. The Plan says the item 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 the member does not need this item. Our physician reviewer found there are no pulmonary function tests to 
assess the severity of the obstructive lung disease or ABG done while stable to confirm chronic carbon dioxide 
(CO2) retention. If the patient does have severe COPD and chronic CO2 retention, may benefit from BiPAP 
with average volume-assured pressure support (AVAPS) during sleep. Medicare does not cover a home 
ventilator when used at settings that can be provided with 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) purchased 
from the out-of-network provider on September 8, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids must be 
purchased through the Plans select hearing aid provider. However, the hearing aids in this case were purchased 
from an out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for 
the hearing aids (V5261 x 2) purchased from the out-of-network provider on September 8, 2022.
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 you are unable to continuously walk around your 
house without a walker and you need to work on your daily living skills. The Plan denied your request. The 
Plan says you have reached your maximum benefit limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from November 8, 2022, 
through March 11, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve SNF care .