Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous tests (95004), provided on August 31, 
2022. 
 
You asked the Plan to pay for the percutaneous tests. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous testing (scratch, puncture, prick), 
immediate type reaction, will be considered medically reasonable and necessary when used to evaluate IgE 
mediated hypersensitivity to inhalants, foods, Hymenoptera (stinging insects), chemicals, and specific drugs 
(e.g., penicillins and macromolecular agents).  
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 percutaneous tests. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there was no documented reason 
prior records could not be acquired to base the new treatment on the prior treatments given to this patient. 
Therefore, this repeat testing is not sufficiently supported and will be considered 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 the percutaneous tests have not been met. Therefore, we decided that the Plan 
does not have to pay for the percutaneous tests (95004), 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. You say that the enrollee needs IRF care to regain strength, 
endurance and mobility to return home and experience a better quality of life. The Plan denied your request. 
The Plan says the enrollee's required services could be administered at a lower level of care. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar orthosis, flexible, provides lumbar support, 
posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the 
intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, 
prefabricated, off-the-shelf (L0625). 
 
You asked the Plan to pre-approve a lumbar orthosis. You say that you have ventral hernia, and the orthosis is 
necessary. The Plan denied your request. The Plan says per information provided, the enrollee reported to have 
ventral hernia on appeal request for additional information. Physical exam notes ventral hernia, no abdominal 
tenderness. The Plan is unable to approve this item as the clinical documentation received, shows no indication 
for need for an abdominal binder. 
 
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 a lumbar orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation provided does not support the use of the requested lumbar 
orthosis. There is insufficient clinical documentation indicating the status of your hernia and the need for the 
lumbar orthosis as an abdominal binder. The clinical documentation is insufficient in terms of physical 
examination findings regarding your hernia and there is limited clinical history regarding the status of your 
ventral hernia and how the lumbar orthosis is being utilized as an abdominal binder. This is not related to spine 
pathology and may be related to soft tissue injury, but there is insufficient clinical history as the status and 
physical examination of your hernia. 
 
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 lumbar orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lumbar orthosis, flexible, provides lumbar support, posterior extends from l-1 to 
below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, 
closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, off-the-shelf (L0625).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferumoxytol (CPT code Q0138). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s) 
Infed (iron dextran) and Venofer (iron sucrose). The Plan states there is no indication our preferred drug(s) 
would likely be: less effective, and/or cause adverse effects for the enrollee. 
 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 Infed (iron dextran) and Venofer (iron sucrose) 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 Ferumoxytol (CPT code Q0138).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from July 14, 2022, to 
July 31, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not aware of a copayment 
after day 20 and understood the authorization of a SNF stay meant it was completely covered. 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 $0 
copayment per day for days 1 to 20 and a $160 copayment per day for days 21 to 100 for each skilled nursing 
facility admission.  
 
 
  You have been asked to pay a total copayment of $2,560 for a SNF stay ($160 per day x 16 days = $2,560). 
This item/service falls within the Skilled Nursing Facility 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 copayment for a SNF stay provided from July 14, 2022, to July 31, 2022.  
 
Your complaint about being unaware of the copayment after day 20 is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a great candidate for an IRF and meets 
all guidelines for admission. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (TENS) supplies 
provided on September 7, 2022. 
 
You asked the Plan to pay for TENS supplies. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the documentation does not support payment. 
 
The Plan must follow Medicare rules. Medicare rules say that proof of delivery documentation is required for 
coverage of DMEPOS items.  
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery of the specific items billed on this claim. Specifically, the delivery information does not support 
whether delivery was made to the enrollees address. Based on this information, we decided that Medicare 
rules for coverage of TENS supplies have not been met. Therefore, we decided that the Plan does not have to 
pay for transcutaneous electrical nerve stimulation (TENS) supplies provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #6. 
 
You asked the Plan to pre-approve a crown. You say that this dental work is medically necessary. The Plan 
denied your request. The Plan says D2740 has been correctly denied. 
 
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 Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our physician reviewer found 
the medical criteria for a crown for tooth #6 have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #6.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on 
September 8, 2022. 
 
You asked the Plan to pay for the PCD. You say that this item was prescribed following surgery to prevent 
thrombotic events. You said that this item should be covered. The Plan denied your request. The Plan says this 
item is not covered. The Plan must follow Medicare rules. Medicare rules say that that PCDs used for the 
prevention of thrombotic events are explicitly non-covered.  The records and your appeal letter confirm that the 
PCD at issue in this case was provided solely for the prevention of thrombotic events following surgery. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) 
provided on September 8, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care (99223) billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial states that procedure code 99223 is an inpatient-
only code billed for outpatient services. However, the case record supports that the claim is for inpatient 
services as place of service (POS) is reported as 21, indicating an inpatient hospital. Additionally, the Plan 
states that code 99223 was billed on a prior claim. The documentation of the prior claim as provided by the 
Plan does not support that code 99223 was previously billed. It is the Plan's responsibility to substantiate its 
denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for inpatient hospital care (99223) billed for date of service 
August 8, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) provided on 
September 5, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the facility is certified by the Substance 
Abuse and Mental Health Services Administration (SAMHSA). You also say that this should be paid. The Plan 
denied your request. The Plan says that the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's rationale is not supported. The file shows that the rules 
cited do not appear to prohibit payment to the program if the prescribing physician is listed on the claim. 
Therefore, we decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) 
provided on September 5, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve 
(Intracept). 
 
You asked the Plan to pre-approve Intracept. You say that this procedure is medically necessary and supported 
by strong science. The Plan denied your request. The Plan says this procedure 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept 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 Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve intraosseous ablation of the basivertebral nerve (Intracept).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of excess skin and tissue of abdomen 
and hernia. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has been approved for laparoscopic ventral hernia repair. The record does not 
include primary source documentation that the enrollee has intertrigo refractory to conservative therapy or has 
functional limitations. The record does not indicate that there are anticipated technical problems performing the 
laparoscopic hernia repair or concerns of wound healing that would be alleviated by performing the requested 
procedure. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgical removal of excess skin and tissue of abdomen and hernia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated wheelchair seat cushion, any size 
(E2609) and custom fabricated wheelchair back cushion, any size, including any type mounting hardware 
(E2617). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested cushions meet generally 
accepted standards of medical practice, and it is clinically appropriate in its type, frequency, extent, duration, 
and delivery setting. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for approval. The custom seating is not necessary particularly because she has not had any pressure 
sores and because she can shift her weight to relieve pressure. The enrollee does not have severe fixed postural 
deformities that would warrant custom seat cushions. The cushion is not medically necessary at this time. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that according to Medicare, accessories including custom fabricated seat or back 
cushions meet criteria if there is a past history of or current diagnosis of a pressure ulcer in the area of contact 
with the seating surface or if there is absent or impaired sensation in the area of contact with the seating surface 
or an inability to carry out a functional weight shift. Additionally, it may be covered if the enrollee has a 
significant postural asymmetry and a licensed/certified medical professional, such as a physical therapist or 
occupational therapist, has noted a prefabricated seating system is not sufficient to meet the enrollee's seating 
and positioning needs. In this case, the documentation available for review does not indicate that the enrollee 
has any active or past pressure injuries or that she is unable to shift her weight. Additionally, a licensed 
professional noted that a prefabricated seating system would be sufficient to meet her seating and positioning 
needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a custom fabricated wheelchair seat cushion, any size (E2609) and custom 
fabricated wheelchair back cushion, any size, including any type mounting hardware (E2617).