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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
25, 2021. 
 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 November 25, 
2021.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary for the patient, and they can be managed 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical repair of a hip fracture after a fall. Their medical problems are stable and there are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
patient has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that this patient 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 pay for a pneumatic compression device (E0675) and accessory 
(E0673) provided on July 28, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and accessory. You say that this was medically 
necessary. The Plan denied your request. The Plan says this is not covered.  
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. If the base PCD is 
not covered, related accessories are 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) and accessory (E0673) provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories for the 
enrollee.  
You asked the Plan to pre-approve the services. 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 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have a neurologic disorder with functional deficits and spasticity. She does not 
require intermittent bladder catheterization and there is no indication she is unable to offload pressure manually 
and would require power tilt and recline. Furthermore, the issues with her current power mobility device can be 
solved with revisions and her chair is less than 5 years old. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system for the enrollee. 
 
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 is no medical proof that this system will help with the enrollee's condition. 
 
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 this system combines airflow oscillation (not high frequency chest wall oscillation), positive end 
expiratory pressure, and nebulization. There is insufficient evidence that this device is effective in the home 
treatment of any 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 the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Volara system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power feature 
(E0955, E2601, K0856, E1028, E2361, E1012, E1002, E2311). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with a single power feature. You say that the 
group 3 power wheelchair with power features is medically necessary. The Plan denied your request. The Plan 
says a group 3 power wheelchair with no power options is more appropriate. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with single power option 
is covered when there is a medical need for a ventilator, or a special drive control (including, but not limited to, 
head control, sip and puff, switch control) or for power tilt or power recline. 
 
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 group 3 power wheelchair with a 
single power feature. Our reviewer says that the type of chair requested is not medically necessary. Our 
physician reviewer found while the patient has a Group 3 qualifying diagnosis, documentation does not reveal 
that the patient uses a ventilator attached to a wheelchair or uses intermittent catheterization. There is no 
evidence of spasticity that needs a power seating system for management. The patient is not at high risk for 
skin breakdown. The request for power tilt exceeds the patient's medical 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 the group 3 power wheelchair with a single power feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single 
power feature (E0955, E2601, K0856, E1028, E2361, E1012, E1002, E2311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve Repatha. The Plan denied your request. The Plan says this drug is a part D 
covered benefit. 
  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 Repatha.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that due to your diagnosis of foot pain and bone 
spurs the orthotics should be approved. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacituzumab govitecan-hziy. 
 
You asked the Plan to pre-approve sacituzumab govitecan-hziy.. You say that you have had two treatments 
prior and have had progress. You say that the requested drug is needed due to the late stage of your cancer. The 
Plan denied your request. The Plan says the requested drug is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 sacituzumab govitecan-hziy.. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
metastatic triple negative breast cancer. She has only received one chemotherapy regimen of 
Cyclophosphamide Methotrexate Fluorouracil (CMF.) The compendia state that coverage of this drug requires 
two prior regiments, at least one in a metastatic 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 sacituzumab govitecan-hziy. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacituzumab govitecan-hziy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chemotherapy regimen to include Oxaliplatin, 
Leucovorin, Irinotecan, Fluorouracil, and Fosaprepitant. 
 
You asked the Plan to pre-approve a chemotherapy regimen to include Oxaliplatin, Leucovorin, Irinotecan, 
Fluorouracil, and Fosaprepitant. You say that the requested chemotherapy regimen (Oxaliplatin, Leucovorin, 
Irinotecan, Fluorouracil, and Fosaprepitant) is medically necessary. The Plan denied your request. The Plan 
says the requested chemotherapy regimen (Oxaliplatin, Leucovorin, Irinotecan, Fluorouracil, and 
Fosaprepitant) is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 a chemotherapy regimen to include 
Oxaliplatin, Leucovorin, Irinotecan, Fluorouracil, and Fosaprepitant. Our reviewer says that the requested 
chemotherapy regimen (Oxaliplatin, Leucovorin, Irinotecan, Fluorouracil, and Fosaprepitant) is not medically 
necessary. Our physician reviewer found the enrollee is with stage IV malignant neoplasm of ascending colon. 
The enrollee has been treated with a right hemicolectomy and 12 cycles of FOLFOX. The enrollee has been 
diagnosed with a mass occupying his entire right chest consistent with the adenocarcinoma of the colonic 
primary tumor. The plan was for the enrollee to begin FOLFIRINOX therapy on March 21, 2022. 
 
The requested use of Fluorouracil is FDA-approved for the palliative care of colon cancer, and may be used in 
combination with oxaliplatin, leucovorin, and fluorouracil. However, the requested regimen of Oxaliplatin, 
Leucovorin, Irinotecan, Fluorouracil, and Fosaprepitant is not supported by NCCN when previous FOLFOX 
therapy was used within the previous 12 months. 
 
The requested use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. The clinical documentation and the current medical literature do not support 
that the requested regimen is reasonably expected to be safe and effective and otherwise reasonable and 
necessary for the enrollee in this case. 
 
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 chemotherapy regimen to include Oxaliplatin, Leucovorin, Irinotecan, 
Fluorouracil, and Fosaprepitant have not been met. Therefore, we decided that the Plan does not have to pre-
approve a chemotherapy regimen to include Oxaliplatin, Leucovorin, Irinotecan, Fluorouracil, and 
Fosaprepitant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a parenteral nutrition infusion pump (B9004) provided on 
September 30, 2021. 
 
You asked the Plan to pay for a parenteral nutrition infusion pump. You say that this was medically necessary. 
The Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) for durable Medical 
Equipment (DME) indicates the place in which the item is being used, i.e., patient's home is 12, skilled nursing 
facility (SNF) is 31, or end stage renal disease (ESRD) facility is 65. 
 
We looked at the file and Medicare rules. The item at issue was billed with POS 65, ESRD facility, but the 
records indicate this item was for use in the enrollees home. Based on this information, we decided that 
Medicare rules for coverage of a parenteral nutrition infusion pump have not been met. Therefore, we decided 
that the Plan does not have to pay for a parenteral nutrition infusion pump (B9004) provided on September 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. The Plan denied your request. The Plan says 
bioimpedance spectroscopy 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 bioimpedance spectroscopy. Our 
reviewer says that the requested bioimpedance spectroscopy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that there is a lack of high-quality comparative trials that 
show superior outcomes of bioimpedance on clinical compared to standard methods for measuring/detecting 
lymphedema. Therefore, without sufficient support from current evidence and guidelines National 
Comprehensive Cancer Network (NCCN), this request for bioimpedance spectroscopy will be considered not 
medically necessary at this time.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on October 16, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you believed there was a $200 reimbursement cost 
regardless of where you purchased. You say that you paid 316.79 expecting a $200 reimbursement. The Plan 
denied your request. The Plan says the eyewear was obtained from an out-of-network provider. 
  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine eyewear when you use a Plan network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Specifically, the eyeglasses were not purchased from a Plan 
network provider. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on 
October 16, 2021.
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 this admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee has no complex wounds. 
 
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 transfer to LTACH is not medically necessary as it would not be clinically 
advantageous. Transfer to a lower level of care may be considered when treatment has completed. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that an inpatient admission is 
medically necessary. The Plan denied your request. The Plan says an inpatient admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found a lower level of care would suffice.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
does not have to pre-approve acute inpatient hospital care.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services (A0429 and A0425) provided on September 16, 
2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because 
these services were reported correctly. The Plan denied your request. The Plan says that this claim was not 
billed with the appropriate diagnosis code. 
 
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 has denied this service based on the diagnosis codes billed 
on the claim. The Plan has not forwarded the claim to show how these services were billed by the provider. 
Additionally, there is limited Medicare guidance in regards to diagnosis code requirements for ambulance 
services. Therefore, we decided that the Plan has to pay for the ambulance services (A0429 and A0425) 
provided on September 16, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve implant supported crowns. You say that you would like these crowns 
covered. The Plan denied your request. The Plan says this service is not covered under your 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant supported porcelain/ceramic crowns (D6065).