Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the disposable under pads (A4554) and non-sterile 
gloves (A4927). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says incontinence garments are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the disposable under pads 
(A4554) and non-sterile gloves (A4927).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you would like reconsideration because 
the requested procedure is medically necessary. The Plan denied your request. The Plan says the Vertiflex 
device is experimental. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental and more research is needed to show its 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149) with seat attachment 
(E0156). 
 
You asked the Plan to pre-approve a heavy-duty walker with seat attachment. You say that the item is 
medically necessary. The Plan denied your request. The Plan says he heavy-duty walker and seat attachment 
are considered not medically necessary as you do not weigh more than 300 pounds. 
 
The Plan must follow Medicare rules. Medicare rules say that if an E0148 or E0149 walker is provided and if 
the beneficiary weighs 300 pounds or less, it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty walker with seat attachment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heavy-duty walker (E0149) with seat attachment (E0156).
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 this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria have not been 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 Euflexxa. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has osteoarthritis of the knees.  The requested medication is a new start. The provided records 
do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's 
preferred step one alternative. The elements of the coverage criteria 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says you are not insulin treated. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient services provided after 
February 12, 2022. 
 
You asked the Plan to pre-approve continuation of inpatient services. You say that the inpatient care is 
medically necessary. The Plan denied your request. The Plan says it was not medically necessary to stay in the 
hospital. 
 
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 continuation of inpatient services. Our 
reviewer says that continuation of inpatient services is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the medical records suggested that you were stable and significantly 
improved from the treatment by February 12, 2022, as you reported feeling better, you were hemodynamically stable, you were able to tolerate oral medications, and you were not in acute distress. A lower level of care 
from February 12, 2022, would have been more appropriate. Therefore, inpatient services after this date will be 
considered 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 continuation of inpatient services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continuation of inpatient services provided after February 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group two power wheelchair with captains chair 
(K0823). 
 
You asked the Plan to pre-approve a group 2 power wheelchair and associated components. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the medical records do not show 
what MRADL in the home are impaired or that you are unable to complete the MRADL with a walker or 
manual 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.  
 
The file does not indicate you have a mobility deficit that impairs your participation in MRADLs or that your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group two power wheelchair with captains chair (K0823).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Supartz FX injection. 
 
You asked the Plan to pre-approve the Supartz FX injection. The Plan denied your request. The Plan says this 
medication is only covered if you have tried and failed the preferred medications or if there is a medical reason 
that you are not able to safely use the preferred medications. 
  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 Supartz FX injection. Our reviewer 
says that Supartz FX is not approved as step criteria is not met. Our physician reviewer found that the enrollee 
has not trialed viscosupplement treatments such as Synvisc, Durolane, and Gelsyn-3. Step therapy, as outlined 
by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons 
these medications were not considered. 
 
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 Supartz FX injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Supartz FX injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the item should be covered. The Plan 
denied your request. The Plan says you are not insulin treated three time a day or require frequent changes to 
your insulin doses. 
 
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 use insulin 
with at least three daily injections or 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 CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positive airway pressure (PAP) device (E0471). 
 
You asked the Plan to pre-approve a PAP device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the device is not being used for the minimum amount of time for continued 
use. 
 The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP for 
a minimum of 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during 
the first three (3) months of initial usage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a positive airway pressure (PAP) device (E0471).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 5th epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the ESI. You say that you would like reconsideration because the ESI is 
medically necessary. The Plan denied your request. The Plan says this request exceeds the frequency 
limitations. 
 
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 ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this request exceeds utilization criteria as discussed 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 the ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the 5th epidural steroid injection (ESI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for coverage of the SNF services. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this enrollee does not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Skilled Nursing Facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit provided on May 7, 2021. 
 
You asked the Plan to reduce the copayment for the office visit. You say that you only saw a nurse practitioner, 
but you are paying for a specialist when the doctor never saw you. You say that they did not bill you until after 
the 60-day period and this should be adjusted to a $5 copayment. The Plan denied your request. The Plan says 
the specialist copayment applied 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 $35 
copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a 
nurse practitioner or physician's assistant or other non-physician health care professionals in the specialist's 
office.  
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner Services Including Doctor's Office Visits" benefit category. The records show the office 
visit was provided in a specialists office. 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 reduce the copayment for the office 
visit provided on May 7, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Rituxan injection. 
 
You asked the Plan to pre-approve the Rituxan injection. You say that you would like reconsideration because 
the requested injection is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet step therapy exception 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 the Rituxan injection. Our reviewer 
says that the documentation in the case file does not support that the enrollee has tried and failed Rituximab-
arrx (Riabni) and rituximab-pvvr (Ruxience) as required by the Plan. Our physician reviewer found the 
documentation does not support that Rituximab-arrx (Riabni) and Rituximab-pvvr (Ruxience) 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 Rituxan injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Rituxan injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on November 8 to November 
29, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 secondary diagnosis code J96.21, defined as Acute 
and chronic respiratory failure with hypoxia. 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 
inpatient hospital care. Our reviewer says that the provided care, billed with DRG 291 and secondary diagnosis 
code J96.21, does not meet criteria for reimbursement. Our physician reviewer found that the hospital noted the 
presence of a query to which the provider reports the enrollee was treated for respiratory failure with 
supplemental oxygen. After further review of the record, though the provider has documented acute respiratory 
failure with hypoxia, the medical record does not otherwise support this condition. The record relates that the 
enrollee presented for shortness of breath and was diagnosed with chronic heart failure (CHF) exacerbation. 
There was also no evidence of treatment consistent with acute respiratory failure, which would include 
administration of oxygen of at least 5 liters per min.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided on November 8 to November 29, 2020.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found you were admitted to the hospital 
with high blood sugar and weakness from nerve damage (peripheral neuropathy). You are now medically stable 
with 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. While you 
have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 
30, 2021, through September 3, 2021. 
 
You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed based on the 
medical documentation. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee is a 48-year-old female with a 
past medical history of a stroke, subdural hematoma and alcohol abuse who was in a skilled nursing facility for 
a left ankle fracture. Based on the medical records provided there is no documentation that the patient required 
skilled nursing services or required skilled therapy services. In addition, daily skilled services were not required 
during the dates in question. The patient was walking household distances with a rolling walker and knee sling 
with stand-by assistance and was stand-by/supervision for transfers. In conclusion, based on the medical 
records provided this patient did not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the nursing facility appeared custodial in this case during the dates in question. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from August 30, 2021, through September 3, 
2021.