Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea 2MG/0.05ML syringe (CPT code J0178). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from the enrollee's prescriber that shows the enrollee has 
tried the preferred drug bevacizumab (Avastin) and it has not worked, or that they have medical reasons that 
prevent the enrollee from using it. 
 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 bevacizumab (Avastin) 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 Eylea 2MG/0.05ML syringe (CPT code J0178).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent routine transportation trips (A0120). 
 
You asked the Plan to pre-approve non-emergent routine transportation trips. You say that you cannot walk 
because of your arthritis and are in a wheelchair. You have physical therapy appointments to attend. The Plan 
denied your request. The Plan says your request for transportation is not approved. Transportation is 
not covered by your benefit plan. 
 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan only covers routine transportation up to 30 days following all inpatient and skill nursing facility 
discharges.  
 
We looked at your request, the records in the case file, and the rules. The EOC confirms that you are only 
covered for routine transportation up to 30 days following inpatient and skill nursing facility discharges. The 
records do not show that you were inpatient or in a skilled nursing facility in the last 30 days, therefore, your 
request is not approved. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-
emergent routine transportation trips (A0120).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mobile x-ray services for an x-ray of your left shoulder 
and arm. 
 
You asked the Plan to pre-approve mobile x-ray services. You say that you do not have transportation to get 
urgent care and the Plan's transportation does not work out for you because it takes too long. The Plan denied 
your request. The Plan says no medical documentation was received showing that your doctor ordered x-rays of 
your left shoulder and arm. 
 
The Plan contract covers care from a primary care provider. The Plan says you must choose a primary care 
provider (PCP) to provide and manage your care. 
 
We looked at the file and the Plans rules. The file shows that the Plan has not received medical documentation 
from your PCP showing that you need the x-ray services. Based on this information, we decided that Medicare 
rules for coverage of mobile x-ray services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve mobile x-ray services for an x-ray of your left shoulder and arm.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array 
(spinal cord stimulator trial) 
 
You asked the Plan to pre-approve spinal cord stimulator trial. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are covered for certain 
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 spinal cord stimulator trial. Our 
reviewer says that the documentation does support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has cervical pain and radiculopathy. The enrollee is status 
post anterior cervical discectomy and fusion at C5-C6. The magnetic resonance imaging also shows disc bulges 
that cause spinal stenosis at C4-C5 and C6-C7. The enrollee takes Diclofenac, Baclofen, Gabapentin, and 
Hydrocodone-acetaminophen. The enrollee has psychological clearance. The physician notes physical therapy. 
The physician notes also state there is no further surgical intervention possible. The enrollee has a clear 
indication for a spinal cord stimulator trial. Therefore, the enrollee meets 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 spinal cord stimulator trial have been met. Therefore, we decided that the Plan 
has to pre-approve percutaneous implantation of neurostimulator electrode array (spinal cord stimulator trial)  
 
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: 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 you need this care. The Plan denied your request. 
The Plan says criteria for admission to the IRF setting have not been met. Your ongoing skilled therapy and 
nursing needs can be provided 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 your 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 you 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 stair lift (E1399). 
 
You asked the Plan to pre-approve a stair lift. You say that the stair lift is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from April 16, 2021, 
to April 22, 2021, billed with diagnosis related group (DRG) code 872. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says DRG 872 is not supported as the diagnosis of Streptococcal sepsis, unspecified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A40.9, defined as 
Streptococcal sepsis, unspecified. We asked our physician reviewer to carefully review the case file and apply 
the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found there was no clinical or laboratory evidence of sepsis. Our reviewer also found that 
the medical records did not support the billing of Streptococcal sepsis, unspecified with DRG 872.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from April 16, 2021, to April 22, 2021, billed with diagnosis related 
group (DRG) code 872.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99152, 99153) provided on May 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
payable. 
 
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, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older". 
 
We asked our coder 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 services. Our reviewer says that the use of code 99152 is 
not supported by the records provided. Our reviewer found that the operative report does not document the 
presence of an independent trained observer, and therefore this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99152 have not been met. 
 
We have also confirmed that code 99153 is an add-on code and has not been billed with an appropriate payable 
primary procedure code. As primary code 99152 is not payable in this case, the add-on code is also not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services (99152, 99153) provided on May 12, 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicting medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee's and able to be furnished safely and effectively only on an inpatient 
basis. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit on June 8, 2022. 
 
You asked the Plan to waive the copayment a specialist office visit. You say that you were told there would be 
no copayments. 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 $25 
copayment for specialist office visits.  
 
 
 
 
 
 You have been asked to pay a $25 copayment for a specialist office visit. This item/service falls within the 
specialist office visits 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 specialist 
office visit on June 8, 2022.
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 requesting inpatient rehabilitation for the 
enrollee. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care 
such as skilled nursing facility (SNF). 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says Medicare does not cover a ventilator for the requested purpose and your needs can be 
met by a bi-level positive airway pressure (BiPAP) device with average volume assured pressure support 
(AVAPS) mode. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, will be denied.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PBRT 
 
You asked the Plan to pre-approve the PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies have not shown that PBRT is better than other treatments for this type of 
cancer. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation 
therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
The most recent American Urological Association (AUA) guidelines state that PBRT offers no clinical 
advantage over other forms of definitive treatment.  
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 PBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the PBRT
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - resin base (CPT code 
D5212) and implant/abutment supported removable denture for edentulous arch-maxillary (D6110). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your benefit has been exhausted for the 2022 Plan year. 
 
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. 
 
Review of the records indicate you received mandibular partial denture - resin base (including 
retentive/clasping materials, rests and teeth) (CPT code D5212) on June 14, 2022. Your 2022 EOC states 
partial dentures (upper and lower) (1 upper and/or 1 lower partial denture every 5 years; therefore, you 
exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve mandibular partial 
denture - resin base (CPT code D5212) and implant/abutment supported removable denture for edentulous 
arch-maxillary (D6110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek diabetic test strips. 
 You asked the Plan to pre-approve the Accu-Chek diabetic test strips. You say that the Accu-Chek brand 
testing supplies are medically necessary. The Plan denied your request. The Plan says the requested brand is 
not covered. A transitional supply has already been provided. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The plan contract states that only OneTouch brand diabetic testing 
supplies are covered. No medical documentation was provided showing that the plan preferred product would 
not meet the enrollee's needs. Based on this information, we decided that Medicare rules for coverage of the 
Accu-Chek diabetic test strips have not been met. Therefore, we decided that the Plan does not have to pre-
approve Accu-Chek diabetic test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an SCS trial is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has coccydynia. He uses topical lidocaine and is not using any other pain medications. He has done physical therapy and has 
psychological clearance. He does not have an evidence-based indication for the SCS trial. The criteria for 
coverage are not met and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.