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

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on 
December 01, 2022. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you do not agree with the 
cost sharing amount. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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. The total you owe is $270.12 ($1350.60 allowed amount x 20% = $270.12). 
Therefore, we decided that the Plan does not have to waive the coinsurance for a denosumab injection provided 
on December 01, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. 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 follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the fracture 
pattern is potentially unstable on computed tomography (CT) imaging. This is a contraindication to 
kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 rendered on July 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 99236 is "Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 services at issue in this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
does not support the CPT code 99236. The documentation available for review does not support that the 
presenting problems were of high severity or that the medical decision was of high complexity. 
 
We looked at this coder'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 pay for procedure code 99236 rendered on July 15, 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 LTACH is medically necessary. The 
Plan denied your request. The Plan says he LTACH is not medically necessary, and the enrollee's needs can be 
met at a lower level of care such as an inpatient rehabilitation or skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute hypoxic respiratory failure secondary to 
COVID-19 pneumonia and has had a complicated hospital course. The record indicates that the enrollee has 
ongoing acute medical issues and still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied.  The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia (D9222/D9223). 
 
You asked the Plan to pre-approve general anesthesia. You say that the enrollee needs this sedation. The Plan 
denied your request. The Plan says the requested service is not a covered benefit. 
 
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 
general anesthesia (D9222/D9223).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. 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 Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Procrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
requested use of Procrit is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical stimulation using Sanexas therapy. 
 
You asked the Plan to pre-approve Sanexas therapy. You say that this therapy service is medically necessary to 
assist with the enrollee's chronic pain. The Plan denied your request. The Plan says the services requested are 
not reasonable or 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 pre-approve electrical stimulation using Sanexas 
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 the requested Sanexas therapy is 
generally not accepted as specific and effective therapy for the enrollees condition. The documentation does 
not reveal that the enrollee requires the unique skills of a professional therapist to provide this treatment, which 
is not the standard of care for the enrollee's symptoms. The documentation does not reveal objective 
electrodiagnostic studies indicating whether the symptoms are due to peripheral polyneuropathy or lumbosacral 
radiculopathy. The requested services are not part of a maintenance program, and the specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design, or deliver a program to 
maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sanexas therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve electrical stimulation using Sanexas therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device for use 
following shoulder surgery. 
 
You asked the Plan to pre-approve a CPM device. You say that this device is necessary for proper recovery and 
healing of your shoulder. The Plan denied your request. The Plan says CPM devices are not covered for use 
after shoulder surgery. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion (CPM) device for use following shoulder surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on November 18, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that the claim needs to be reprocessed. The 
Plan denied your request. The Plan says self-administered drugs do not fall under Part B coverage. 
   
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 pay for self-administered drugs provided 
on November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve wheelchair ramp. You say that the enrollee needs these ramps to make their 
daily lives better. The Plan denied your request. The Plan says the requested item is not covered by Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you do not agree with this denial. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit-to-stand frame/table system. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is convenience item that is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a combination sit-to-stand frame/table system.
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 always have to return to the hospital when 
released without inpatient rehabilitation. You say you need this service. The Plan denied your request. The Plan 
says the IRF care is not medically necessary, and your needs can be met at a lower level of care such as a 
skilled nursing facility, home with home health services, or home with outpatient therapy. 
 
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 you were admitted for urinary tract infection and normal pressure hydrocephalus. 
Your medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for foot care. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says medically necessary care is available in-network. 
 
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 
an out-of-network referral for foot care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the request for a home mechanical ventilator set in targeted tidal volume, 
volume-assured pressure support (TTV-VAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel 
positive airway pressure (BiPAP) is not covered. 
 
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. Although no clinical information was originally provided with the appeal, the 
plan has not provided any evidence to show that they requested any information for this appeal. Therefore, we 
decided that the Plan has to pre-approve a home mechanical ventilator.  
 
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 Artacent wound, per sq cm. 
 
You asked the Plan to pre-approve Artacent wound, per sq cm. 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 follows Medicare rules. Medicare rules say that chronic wounds are defined as wounds that do not 
respond to standard wound treatment for at least a 30-day period during organized comprehensive conservative 
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 Artacent wound, per sq cm. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found records do not 
demonstrate that the enrollee has had a failed response for at least a 30-day period. There are no recent measurements provided. The review has determined that the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Artacent wound, per sq cm have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Artacent wound, per sq cm.
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 LTACH is medically necessary. You 
say the enrollee will be best served due to the level of acuity at an LTACH and the complexity of this case. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs such 
as an inpatient rehabilitation facility or skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with weakness and determined to have acute metabolic 
encephalopathy, hypernatremia, severe cervical stenosis with radiculopathy and questionable L2-L3 discitis/osteomyelitis. The record indicates that the enrollee has ongoing acute medical issues and still requires 
acute care services. The enrollee continues to receive acute care services, and these have not been denied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs to be transferred to 
an LTACH versus a lower level of care as their condition has stabilized. The Plan denied your request. The 
Plan says an LTACH admission is not medically necessary, and the enrollee's needs can be met in another 
setting 
 
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 that the enrollee is unstable and only requires short-term additional acute care 
hospital services that can be safely provided at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.