Persius/hicric huggingface dataset:
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 to return to 
maximum level of functioning. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation care. There is not a reasonable expectation that the enrollee will be able to fully participate in - 
and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 continuous glucose monitor (CGM) 
sensors. 
 
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 criteria for coverage are not 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 treat with 
insulin three or more times per day or use an insulin pump. 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 Freestyle Libre 2 continuous glucose monitor (CGM) sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) and an oxygen concentrator 
(E1390) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a home ventilator and an oxygen concentrator. You say that you disagree 
with the denial. The Plan denied your request. The Plan says the enrollee must use network providers to get 
medical care and services. The requested supplier is not in the enrollee's network plan. There are several 
medical supply providers in the enrollee's plan who can provide the equipment needed. 
 
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 
a home ventilator (E0466) and an oxygen concentrator (E1390) to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit, diagnostic radiology, 
incision and drainage of an abscess provided from March 15, 2022, to August 8, 2022. 
 
You asked the Plan to waive the coinsurance for the office visit, diagnostic radiology, incision and drainage of 
an abscess. You say that the cost share is not correct because this provider is in-network. 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 30% 
coinsurance for doctor visits and diagnostic testing.  
 
 You have been asked to pay a 30% coinsurance for the office visit, diagnostic radiology, incision and drainage 
of an abscess. This service falls within the physician/practitioner services, including doctors office visits and 
outpatient diagnostic tests and therapeutic services and supplies 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 coinsurance for an office visit, diagnostic radiology, incision and drainage of an abscess provided 
from March 15, 2022, to August 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services denied with denial codes B, C, G, 
K, and O rendered from February 25, 2022, to April 7, 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 a cost outlier review was performed which resulted in findings.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 terms of denial code G, 
multiple items listed on the itemized bill summary were denied correctly as these services would be considered 
routine and would not be separately reported.  In terms of denial code B, the itemized bill documents two lines 
for computed tomography of the head/brain without contrast for date of service February 23, 2022. This 
procedure was not found in the medical records, or found to have been rendered twice. In terms of denial code 
C, the medical record does not include the testing, or a physician order. Therefore this charge denied correctly. 
In terms of denial code O, the itemized bill documents telemetry, post-critical care unit (CCU) for dates of 
service 3/29 - 4/6. The telemetry charges for 3/29, 3/30 and 3/31 were reversed.  However medical records 
regarding telemetry for: 4/1, 4/3, 4/4, 4/5, and 4/6 are not supported for constant supervision and assessment 
past post surgery. 
 
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 inpatient hospital services denied with denial codes B, C, G, K, and O rendered from February 
25, 2022, to April 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is still medically necessary. The Plan 
denied your request. The Plan says that SNF care is no longer medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have documented skilled nursing and skilled therapy needs. You 
appear to have reached a plateau in function. Your care needs can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 to regain maximum function. The Plan denied your request. The Plan says that the enrollee does not 
meet the Medicare criteria for admission to an IRF. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dexamethasone tablets (J8540). 
 
You asked the Plan to pre-approve dexamethasone tablets. You say that the enrollee has chronic obstructive 
pulmonary disease (COPD) and tested positive for COVID-19. The Plan denied your request. The Plan says the 
oral dexamethasone is not a covered benefit of Medicare Part B in this case. 
 
 
 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 dexamethasone tablets 
(J8540).  
 
Benefits for dexamethasone tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and expandable 
controller (E2311, E2313, E2377) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the power seat elevation feature and expandable controller. You say that 
these items are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary. Power seat elevation features are non-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 power seat elevation feature and 
expandable controller. Our reviewer says that the requested items are not medically necessary. Our physician 
reviewer found the records show that the enrollee has adequate strength to operate the power features with the 
standard switches. The requested power seat elevator is not covered. 
 
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 power seat elevation feature and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and 
expandable controller (E2311, E2313, E2377) for an approved power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erleada tablets. 
 
You asked the Plan to pre-approve Erleada tablets. You say that the enrollee is currently on Lupron and 
apalutamide. The Plan denied your request. The Plan says Erleada is a self-administered drug, and does 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 pre-approve Erleada tablets.  
 
Benefits for Erleada tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation does not support that he 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain his functional status. The 
enrollee can receive further services at 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 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 proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested proton beam 
radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested proton 
beam radiation therapy 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 proton beam radiation therapy. Our 
reviewer says that the requested proton beam radiation therapy is not medically necessary. Our physician 
reviewer found the enrollee is being offered pelvic/prostate radiotherapy to be followed by a brachytherapy 
boost. Routine use of proton therapy for pelvic/prostate radiation is not within accepted standards of medical 
practice.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and appliance to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance to be provided by an OON 
provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says 
there are in-network providers available to the enrollee that can provide the items being requested. 
 
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 
a pneumatic compression device and appliance to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services (99497-25 and G0109-59) provided 
on August 9, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate and the definition of G0109 is diabetes outpatient self-management 
training services, group session (2 or more), per 30 minutes.  
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 outpatient services. Our reviewer found the 
documentation does not support advanced care planning that would qualify for CPT code 99497-25 or that 30 
minutes of diabetic self-management training occurred. 
 
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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the outpatient services (99497-25 and G0109-59) provided on August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair identified with 
miscellaneous code E1399. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a Group 3 power wheelchair have been met. Specifically, the requested item has not been sufficiently identified in the case record. We are unable to 
determine the medical necessity of an item identified only with a "miscellaneous" code. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair identified with miscellaneous code 
E1399.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the enrollee has had steroid injections as well as 
physical therapy and medication with no positive results. The Plan denied your request. The Plan says this 
request cannot be approved because they do not see that the enrollee has tried a preferred shot and it did not 
help with their knee pain. The Plan also says that they did not see that the enrollee has a medical reason that the 
preferred injection cannot be used. 
 
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 Euflexxa. Our reviewer says that the 
enrollee does not meet the coverage criteria for Euflexxa. Our physician reviewer found the case file does not 
contain documentation of trial and failure of Orthovisc or Synvisc. Our reviewer also found that the 
documentation does not support that Orthovisc or Synvisc would likely be less effective, and/or would likely 
have adverse effects 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.