Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
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. You say that your doctor has not been in the office, and you would 
like the SSBCI to be sent again. The Plan denied your request. The Plan says there is a lack of clinical 
information and support. 
 
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 special supplemental benefits for the 
chronically ill (SSBCI). have been met. Specifically, in order to approve this request, a signed attestation form 
is needed from your provider showing you meet the program's criteria. The Plan says that this document was 
not received. There are also no medical records that were provided with this request. Therefore, we decided 
that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI), lower extremity, 
any joint (73723), and MRI of pelvis (72197). 
 
You asked the Plan to pre-approve the MRIs. You say that you are due for follow-up MRIs. The Plan denied 
your request. The Plan says the requested MRI for the lower extremity and pelvis are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRIs. Our reviewer says that the 
requested MRIs are not medically necessary. Our physician reviewer found the provided documentation 
describes a "prior MRI" which did not reveal a lesion. The reviewer found that no such report is in the 
submitted records. An area of abnormal bone scan activity mandates imaging correlation. Such a workup 
begins with plain films and then computed tomography (CT) or MRI if the abnormality in question is not 
clarified. The reviewer found that since this information is not provided, the medical necessity of the requested 
MRI of the lumbar spine and left hip is not yet established and therefore cannot be approved. 
 
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 MRIs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI), lower extremity, any joint (73723), and MRI of pelvis 
(72197).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided 
from December 25, 2021, to December 29, 2021. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the provided documentation 
supported the diagnosis code that was billed. The Plan denied your request. The Plan says the provided 
documentation does not support the billing of diagnosis code N17.0, defined as acute renal failure with tubular 
necrosis. 
 
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 diagnosis code, N17.0, defined as acute renal failure 
with tubular necrosis. 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 an additional amount for the 
inpatient care. Our reviewer says that the provided documentation does not support the billing of diagnosis 
code N17.0. 
 
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 
an additional amount for the inpatient hospital care provided from December 25, 2021, to December 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has prostate cancer. He has 
not tried and failed the Plan's required drug, Eligard. The records do not show that the required drug would be 
contraindicated or less effective; therefore, Lupron Depot is 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 Lupron Depot.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional chiropractic services. 
 
You asked the Plan to pre-approve additional services. You say that  additional chiropractic services are 
medically necessary. The Plan denied your request. The Plan says your condition seems to be stable, and once 
your clinical status has remained stable for a given condition, further manipulative treatment is considered 
maintenance therapy and therefore is not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic services.  Our reviewer 
says that additional chiropractic services is not medically necessary. Our physician reviewer found that the 
enrollee has pain but the record does not document subluxation by examination or radiographs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional chiropractic services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) 
procedure. 
 
You asked the Plan to pre-approve a MILD procedure. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MILD procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MILD procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 MILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a minimally invasive lumbar decompression (MILD) procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RhinAer procedure. 
 
You asked the Plan to pre-approve RhinAer procedure. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the RhinAer procedure is only 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 RhinAer procedure. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has vasomotor rhinitis and chronic rhinitis. His symptoms include 
postnasal drip, nasal congestion and drainage, and chronic clearing of the throat. The enrollee reported 
significant improvement of his nasal drainage with the use of Atrovent nasal spray. The FDA granted 510(k) 
clearance for the RhinAer Stylus, a nonsurgical device indicated for treating chronic rhinitis. The RhinAer Stylus has not been approved for marketing by the FDA. There is insufficient evidence to support that the 
RhinAer Stylus is medically reasonable and necessary for the management of the enrollee's condition. 
Therefore, the enrollee does not meet criteria for the requested services? 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RhinAer procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve RhinAer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) therapy. 
 
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 CPAP therapy 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 criteria for coverage are not met. Our physician reviewer found the home sleep study report dated February 
7, 2021 indicates there is no diagnosis of obstructive sleep apnea (OSA). The apnea-hypopnea index (AHI) is 
less than 5.0. The criteria for coverage are not met and the CPAP is 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 continuous positive airway pressure (CPAP) therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related osteoporosis without osteoporotic fracture. The provided records do not 
indicate that the enrollee has tried and failed zoledronic acid. The record does not indicate that the enrollee has 
a contraindication to, or would have an adverse effect from zoledronic acid. Therefore, the enrollee does not 
meet step therapy criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve non-emergency medical transportation. 
 
You asked the Plan to pre-approve the transportation services. You say that you need transportation to see an 
allergist to be approved. The Plan denied your request. The Plan says that there was no specific code that was 
requested. The Plan also says that since there is no specific code requested, coverage cannot be determined. 
 
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 file shows that routine transportation services are covered as a 
supplemental benefit under the plan. Therefore, we decided that the Plan has to pre-approve non-emergency 
medical transportation.  
 
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy 
program. The member continues to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that she would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that the member 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 her functional status. The member 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: 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 LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with acute hypoxic respiratory failure in the setting of sepsis from necrotizing cavitary 
pneumonia.  The record indicates that the enrollee still requires acute care services before transitioning to a 
lower level of care.  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 he is not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested 
service cannot be recommended. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special power wheelchair, group 2 power wheelchair, 
with two (2) or more power seat options, includes power tilt and power recline options (K0861, E1007, E2311, 
E1012, E2361, E2313, E2377, E1028, E2323, E2620, E2607, E0955). 
 
You asked the Plan to pre-approve a special power wheelchair and power options. You say that the requested 
wheelchair is medically necessary. The Plan denied your request. The Plan says you do not have medical need 
for multiple power options included with the wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 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 special power wheelchair and power 
options. Our reviewer says that the service/items are not medically necessary. Our physician reviewer found 
records do not support that you are high risk for skin breakdown. There is no documented current pressure 
ulcer or history of pressure ulcer or flap surgery. You do not utilize urinary bladder self-catheterization and no 
increased muscle tone or spasticity is documented. Records do not document that 90-degree flexion is 
prevented at the knee or the presence of significant lower extremity edema. Provided records document that 
you have 3-/5 bilateral upper extremity strength and are independent with operating the power wheelchair with 
alternate controls thus indicating you have adequate upper extremity strength and function to operate the 
wheelchair's power options with their own switches. In the absence of power tilt and recline, the headrest does 
not meet coverage criteria. 
 
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 special power wheelchair and power options have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a special power wheelchair, group 2 power wheelchair, with 
two (2) or more power seat options, includes power tilt and power recline options (K0861, E1007, E2311, 
E1012, E2361, E2313, E2377, E1028, E2323, E2620, E2607, E0955).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the plan's preferred 
drugs, Orthovisc or Supartz FX. 
 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 
step therapy criteria have not been met. Our physician reviewer found the medical records provided do not 
indicate that the enrollee has tried and failed the required drugs. The reviewer found that there is no indication 
that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
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 (J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. In addition, code 99000 has 
a status code of B. This means that payment for this code is always bundled into payment for other services 
not specified and no separate payment can be made. Therefore, we decided that the Plan does not have to pay 
for lab services provided on October 4, 2021.