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

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says this is not 
medically necessary.  
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered for the 
indications established in the applicable LCD. 
 
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 injection. Our reviewer says that the 
requested services are not medically reasonable and necessary in this case. Our physician reviewer found that 
according to the coverage criteria, at least 4 weeks of non-invasive conservative care (physical therapy or 
chiropractic therapy) is required before an injection can be approved. The review has determined that the 
requested injections are not medically reasonable or necessary according to the coverage criteria established in 
the applicable 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom manual wheelchair/base (CPT code K0008). 
 
You asked the Plan to pre-approve the wheelchair. You say that your current wheelchair has been deemed 
dangerous. The Plan denied your request. The Plan says your request is not medically necessary because your 
records show you do not have documentation supporting the need for a custom manual wheelchair base, or 
evidence of a standard written order from your doctor. 
 
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 wheelchair. Our physician reviewer 
found a custom manual wheelchair/base (CPT code K0008) is not medically necessary per Medicare's LCD: 
Manual Wheelchair Bases (L33788). The documentation does not reveal a home assessment that indicates you 
can safely maneuver the requested wheelchair in the home. The documentation does not support that you need 
a specific custom configuration to address your physical and/or functional deficits that cannot be met using one 
of the standard manual wheelchair bases plus an appropriate combination of wheelchair seating systems, 
cushions, options or accessories (prefabricated or custom fabricated). 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the custom manual wheelchair/base (CPT code K0008).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the lab services (84100, 87205, 89051, 87070) provided 
from February 23, 2022, to February 27, 2022. 
 
You asked the Plan to hold you harmless for lab services. You say that these services were referred by your 
provider and you only agreed to have them done because you were assured that they would be covered by your 
insurance. The Plan denied your request. The Plan says that these services were billed with an incorrect 
modifier and were performed by a provider who was not in-network at the time of services. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You say that you were referred for lab services by a contract provider. The Plan has not made any attempt to 
clarify if the referring provider is part of their network. The file does not show that the Plan provided notice 
that lab services would not be covered. Under Medicare rules, this means the lab services are considered 
approved by the Plan. In addition, the Plan denied these services on the basis that they were not billed 
according to Medicare regulations. As the enrollee, you are not responsible for billing issues between the 
provider and the Plan. Therefore, we decided that the Plan has to hold you harmless for the lab services (84100, 
87205, 89051, 87070) provided from February 23, 2022, to February 27, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and 
related supplies (K0554, K0553). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM and related supplies. You say that the requested items 
are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have not been 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 you do not use insulin with at least 
three daily injections nor require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G6 continuous glucose monitor (CGM) and related supplies (K0554, K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cranial prosthesis (wig) you purchased on January 15, 
2022. 
 
You asked the Plan to pay for the wig. You say that this wig is needed because of permanent hair loss due to 
cancer treatment.  You had a prescription from your doctor and your alopecia is permanent. The Plan denied 
your request. The Plan says this item is not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the cranial prosthesis 
(wig) you purchased on January 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the safety flag, walker holder, and cup holder. 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The safety flag and walker holder are typically not for home use. The cup holder is a convenience item and is 
not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the safety 
flag, walker holder, and cup holder.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an outpatient diabetic cataract surgery provided on 
September 20, 2021 
 
You asked the Plan to waive the cost for an outpatient diabetic cataract surgery. You say that you were 
unaware that the cost for this procedure would be this high when the provider did a second part of the 
procedure. The Plan denied your request. The Plan says the cost applied was correct 
 
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 $450 
copayment for Medicare-covered visit to an ambulatory surgical center, and a 20% coinsurance ($83.85) for 
outpatient hospital services not identified ($450 + $83.85 = $533.85). 
 
You have been asked to pay a cost of $53385 for an outpatient diabetic cataract surgery. An outpatient diabetic 
cataract surgery falls within the Medicare-Covered Visit to An Ambulatory Surgical Center 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 cost for an outpatient diabetic cataract surgery 
provided on September 20, 2021
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carboplatin, paclitaxel protein-bound, pembrolizumab 
(Keytruda) (CPT code(s): J9264, J9271, J1100). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says you have not tried and failed the preferred step therapy drugs: Taxol (conventional 
paclitaxel) OR Taxotere (docetaxel). The Plan states there is no indication their preferred drug(s) would likely 
be: less effective, cause adverse effects, and/or hypersensitivity reactions for you. The Plan states there is no 
evidence you have contraindications to the hypersensitivity pre-medications used with the step therapy drugs.  
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 Taxol (conventional paclitaxel) OR Taxotere (docetaxel) before they will 
approve the requested drug. In this case, you have 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 you. 
 
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 carboplatin, paclitaxel protein-bound, pembrolizumab (Keytruda) (CPT code(s): J9264, 
J9271, J1100).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane (CPT code J9264). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs: Taxol 
(conventional paclitaxel) OR Taxotere (docetaxel). The Plan states there is no indication our preferred drug(s) 
would likely be: less effective, cause adverse effects, and/or hypersensitivity reactions for the enrollee. 
 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 case file does not contain documentation of trial and failure of Taxol (conventional paclitaxel) OR 
Taxotere (docetaxel). The documentation does not support that Taxol (conventional paclitaxel) OR Taxotere 
(docetaxel) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Abraxane (CPT code J9264).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in this enrollee's clinical management. 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 ILR have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
ILR (CPT code 33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve a partial psychiatric hospitalization. 
 
You asked the Plan to pre-approve a partial psychiatric hospitalization. You say that your psychologist 
recommended the partial hospitalization. The Plan denied your request. The Plan says the documented clinical 
findings do not justify the level of care requested. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
  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 partial psychiatric hospitalization. Our 
reviewer says that you do not meet the Medicare criteria for continued inpatient psychiatric care. Our physician 
reviewer found it is not expected you would improve in a reasonable period of time beyond the dates in 
question as you are not showing any dangerousness to self or others, tolerating medication and not showing any 
perceptual disturbance or psychosis including auditory or visual hallucinations. Our reviewer also found that it 
does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
hospitalization level of care rather than 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 a partial psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a partial psychiatric hospitalization.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (A0431), and air mileage (A0436) provided on March 2, 2022. 
 
You asked the Plan to pay for the air ambulance services. You say that it was medically necessary to transport 
the enrollee to the nearest trauma center. The Plan denied your request. The Plan says the air ambulance 
services were not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does support that the enrollee suffers from an illness or injury that contraindicates transportation 
by any means other than ambulance. The reviewer found that the documentation does not support that the 
enrollee's condition was such that the time needed to transport a patient by ground, or the instability of 
transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. 
The reviewer also found that the enrollee's vital signs were stable and the ground transport time of 
approximately 60 minutes would not have posed a threat to their survival or have seriously endangered their 
health. Therefore, the reviewer found that the transport by air ambulance was not 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 the air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance service, conventional air services, transport, one way (A0431), and 
air mileage (A0436) provided on March 2, 2022.
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 enrollee is not at baseline to go home. The Plan 
denied your request. The Plan says the enrollee does not need to be seen by a rehabilitation physician three 
times a week. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for respiratory failure and pneumonia. His medical 
problems are stable. The complexity of the patient's nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from August 6, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 physician reviewer 
found you no longer qualifies for SNF coverage. You do not have documented skilled nursing needs. You do 
not have documented skilled therapy needs. You appear to be at/near a plateau in function. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs, custodial and intermittent, can, as a practical matter, 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 continuation of SNF care from August 6, 2022, forward.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of 72128 and a second unit of 72131 billed for 
date of service March 18, 2022. 
 
You asked the Plan to pay for additional units of code 72128 and 72131. You say that these services were 
reported correctly and are supported in the medical record. The Plan denied your request. The Plan says these 
services were not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 additional units of code 72128 and 72131 Our reviewer says 
that additional units of 72128 and 72131 are not supported in the medical records. Our coder found that the 
medical records support one lumbar spine computed tomography (CT) and one thoracic spine CT were 
provided on the date in question. No documentation of additional CTs were provided, and therefore the 
additional units cannot be verified. Of note, there was also no additional documentation found to support the 
medical necessity of additional CT scans.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional units of code 72128 and 72131 have not been met. Therefore, we 
decided that the Plan does not have to pay for a second unit of 72128 and a second unit of 72131 billed for date 
of service March 18, 2022.