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

 
We decided that the Plan does not have to pre-approve Yervoy (J9228) and Opdivo (J9299). 
 
You asked the Plan to pre-approve Yervoy and Opdivo. The Plan denied your request. The Plan says there is a 
lack of information regarding biomarker testing. The Plan also says that in order to make a decision on this 
case further biomarker testing is required. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Yervoy and Opdivo. Our reviewer says 
that Yervoy and Opdivo are not reasonable and necessary. Our physician reviewer found the relevant Medicare 
compendia state that these drugs cannot be approved until the tests for estimated glomerular filtration rate 
(eGFR) and anaplastic lymphoma kinase (ALK) come back as wild-type. These tests results have not been 
made available yet. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy and Opdivo have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy (J9228) and Opdivo (J9299).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service March 5, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
70450-26 is a column II code to column I code 70496-26. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service 
March 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found neither the Life2000 System or a 
home ventilator are medically necessary. It is unclear from the record what is being requested; the most recent 
order from July 11, 2022, is for a home ventilator. The enrollee may benefit from bilevel positive airway 
pressure (bipap) during sleep, which can provide the average volume-assured pressure support (AVAPS) mode 
of support. Medicare does not cover a home ventilator when used as bipap. A backup battery and alarms are not medically necessary, because a few hours or one night without the ventilator does not represent an immediate 
risk. The Life2000 System is not a true ventilator and has not been shown to be beneficial in the treatment of 
chronic lung disease. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor sensor 
(K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre sensor. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor sensor (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick catheter. 
 
You asked the Plan to pre-approve these services. You say that the catheter is needed to prevent nighttime falls 
using the bedside commode. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a Purewick catheter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric admission provided from October 
11, 2021, to October 19, 2021. 
 
You asked the Plan to pay for the inpatient psychiatric admission. You say that you would like a retrospective 
review based on medical necessity criteria. The Plan denied your request. The Plan says the medical necessity 
criteria for coverage are not met for the acute inpatient stay after the last certified day. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 psychiatric admission. Our 
reviewer says that the enrollee did not meet the Medicare criteria for the inpatient psychiatric admission. Our 
physician reviewer found it was not expected this enrollee would improve in a reasonable period of time as he 
did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing 
any behavioral issues. Our reviewer also found that it did not appear medically necessary and reasonable to 
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient psychiatric admission provided from October 11, 2021, to 
October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stationary compressed gaseous oxygen system, rental; 
includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (E0424).  
You asked the Plan to pre-approve the oxygen tank. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the information received does not comply 
with the rules established by Medicare. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 oxygen tank. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has hypoxemia with exertion. A stationary oxygen concentrator and portable 
oxygen concentrator have been requested and are appropriate. But an additional stationary oxygen tank for 
backup purposes is not necessary and is not covered by Medicare. 
 
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 oxygen tank have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Stationary compressed gaseous oxygen system, rental; includes container, contents, 
regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (E0424).
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 requested item is a medical necessity for 
you. The Plan denied your request. The Plan says medical necessity rules for coverage of the requested item 
have not been met. 
 
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 requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that you have had a Trilogy ventilator since May 2021. However, the average volume-assured pressure support 
(AVAPS) mode can be provided via a bi-level positive airway pressure (BiPAP) device, and Medicare does not 
cover a home ventilator when used as BiPAP.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 fractions of intensity-modulated radiation therapy 
(IMRT). 
 
You asked the Plan to pre-approve 16 fractions of IMRT. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 16 fractions of IMRT. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the additional sixteen sessions of IMRT are not medically necessary. The 28 sessions 
already approved are medically reasonable and necessary. Hypofractionation has shown little or no difference 
in outcomes when compared to conventional fractionation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 16 fractions of IMRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 fractions of intensity-modulated radiation therapy (IMRT).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove an additional 12 physical therapy visits. 
 
You asked the Plan to preapprove additional physical therapy. You say that therapy is needed for stabilization 
and maintenance of existing neurological function. You also say you need therapy to aid in pain relief. The 
Plan denied your request. The Plan says you have had 22 approved therapy visits and have been taught 
exercises that are safe for you to do with staff in a long-term care facility. The Plan says the additional 12 
therapy visits are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 preapprove additional physical therapy. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the requested skilled therapy is generally 
accepted as an effective treatment for spinal cord injuries with impaired mobility and function. However, there 
are no recent evaluations indicating your progress with strength and function in relation to mobility and 
performance of activities of daily living.  
 
Until further documentation is provided, continued physical therapy would be considered maintenance in 
nature and would not require the skilled care of a physical therapist. Since there are no recent medical records 
indicating that you require physical therapy for maintenance of mobility and function, the requested additional 
physical therapy cannot be considered 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 additional physical therapy have not been met. Therefore, we decided that the 
Plan does not have to preapprove an additional 12 physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic surgery to the face to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve plastic surgery to the face to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
plastic surgery to the face to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 11, 2022, to January 16, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford the 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $250 per 
day for days 1-5 and $0 per day for days 6-90 for each inpatient admission.  
 
The file shows that you were in the hospital from January 11, 2022, to January 16, 2022. You have only been 
asked to pay $250 per day for 3 days of inpatient care. The total for your stay is $750 ($250 copayment x 3 
days = $750). The inpatient care falls within the Inpatient Hospital Care 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 inpatient hospital care provided from January 11, 2022, to January 
16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve a SIJ RFA. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested 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 a sacroiliac joint radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has completed two diagnostic sacroiliac joint 
(SIJ) injections with greater than 80% improvement and significant improvement in functional activities of 
daily living and sleep as a result of the procedure; however, severe SIJ pain has returned resulting in functional 
compromise and sleep interference. Other treatment modalities have included medications, heat, muscle 
relaxants, transcutaneous electrical nerve stimulation (TENs) unit, home exercise program, and trigger point 
injections. Sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of 
sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for 
denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SIJ RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sacroiliac joint (SIJ) radiofrequency ablation (RFA).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 hours per week of a home health aide. 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says there are no skilled nursing needs. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 additional hours. Our reviewer says 
that the requested hours are not medically reasonable or necessary. Our physician reviewer found there are no 
documented skilled nursing or skilled therapy needs. As such, home health services, including associated aide 
services, are not shown to be medically necessary or reasonable. 
 
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 additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 14 hours per week of a home health aide.