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

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a semi-electric hospital bed 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 a semi-electric 
hospital bed can be provided through an in-network provider. 
 
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 semi-electric hospital bed to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care, per day, for the evaluation and 
management of a patient (CPT code 99223) provided on July 9, 2022. 
 
You asked the Plan to pay for the service. You say that the providers are of two (2) different specialties. The 
Plan denied your request. The Plan says the service is not supported by the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the service have been met. No 
documentation was received to show this visit was the initial inpatient encounter by the physician with this 
enrollee. Therefore, we decided that the Plan does not have to pay for initial hospital care, per day, for the 
evaluation and management of a patient (CPT code 99223) provided on July 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission following a reverse total shoulder 
arthroplasty (23472). 
 
You asked the Plan to pay for an inpatient admission. The Plan denied your request. The Plan says the reverse 
total shoulder arthroplasty is currently approved as an ambulatory procedure. The Plan also says there is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 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 an inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for an inpatient admission are met in this case. Our 
physician reviewer found a reverse total shoulder arthroplasty procedure was requested and approved. Our 
reviewer also found that the records provided for review did not reveal any unstable condition or clinical 
evidence to suggest they would need inpatient services that would likely cross 2 midnights for this typically 
ambulatory procedure due to its relative low risk and lower complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for an inpatient admission following a reverse total shoulder arthroplasty (23472).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve memantine HCl tablet. 
 
You asked the Plan to pre-approve memantine HCl. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered under Medicare Part B. 
 
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 memantine HCl tablet.  
 Benefits for memantine HCl 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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the 
enrollee has severe obesity, obstructive sleep apnea (OSA), and heart failure with reduced ejection fraction 
(HFrEF). A diagnosis of chronic obstructive pulmonary disease (COPD) was entertained, but pulmonary 
function testing showed restriction without obstruction. Actual results of spirometry were not provided. There have been repeated admissions for heart failure.  One arterial blood gas (ABG) test from 2021 was consistent 
with chronic CO2 retention.  A sleep study December 12, 2022, confirmed OSA; neither CPAP nor BiPAP 
completely eliminated the sleep disordered breathing.  BiPAP with ASV or AVAPS was not tried, and there 
was no trans-cutaneous CO2 measurement. This enrollee may benefit from a titration sleep study using BiPAP 
with AVAPS or ASV, including monitoring of transcutaneous CO2. AVAPS and ASV can be provided via 
BiPAP. Medicare does not cover a home ventilator when used as BiPAP. Also, use of a ventilator may be 
contraindicated in the presence of HFrEF. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 due to the enrollee's multiple medical issues and long 
hospitalization, the enrollee needs the close medical supervision of acute inpatient rehab and is motivated to 
participate in therapy. The Plan denied your request. The Plan says criteria for admission to the IRF setting 
have not been met. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that Tempus testing has been ordered. You say that 
results will not be in before the enrollee needs to start treatment. You also say that this drug is medically 
necessary for the enrollee's treatment. The Plan denied your request. The Plan says that the requested drug is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
requested drug, Keytruda, is medically necessary. Our physician reviewer found the request for Keytruda to be 
used in combination with carboplatin and paclitaxel is approved by the Food and Drug Administration (FDA) 
since histology cannot determine adenocarcinoma versus squamous. Therefore, the reviewer found that the 
request for Keytruda is medically reasonable and 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda (J9271).  
 
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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found this enrollee has 
severe obesity, and was recently hospitalized with altered mental status, severe sepsis, and urinary tract 
infection (UTI). There is no diagnosis of chronic obstructive pulmonary disease (COPD), thoracic restrictive 
disease, or neuromuscular disease. An arterial blood gas (ABG) test on December 27, 2022, showed alkalotic pH and normal PaCO2.  ABG on December 31, 2022, showed acute hypercarbic respiratory failure, with pH 
7.28, PaCO2 60. The enrollee's circumstances on those dates were not provided. There is no documentation of 
chronic CO2 retention with ABG done while stable. If the enrollee has chronic CO2 retention, she may benefit 
from CPAP or BiPAP during sleep. The records do not indicate that this has been tried as an outpatient. 
Medicare does not cover a home ventilator when used as BiPAP, or in the treatment of obesity hypoventilation 
syndrome (OHS). 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spineology Optimesh implants (22853). 
 
You asked the Plan to pre-approve Spineology Optimesh implants. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this service is experimental and non-covered. 
 
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 Spineology Optimesh implants. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Optimesh implant is considered 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 Spineology Optimesh implants have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Spineology Optimesh implants (22853).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 8341, 88342, 88381, and 88360 billed for 
date of service February 14, 2022. 
 
You asked the Plan to pay for procedure code(s) 8341, 88342, 88381, and 88360. The Plan denied your request. 
The Plan says this code is included in the facility payment and is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 8341, 88342, 88381, 
and 88360. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 8341, 
88342, 88381, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure 
code 8341, 88342, 88381, and 88360 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 8341, 88342, 88381, and 88360 billed for date of service February 14, 2022.
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 the enrollee will improve overall mobility, strength, 
endurance, and balance in order to maximize their level of independence and return home safely. The Plan 
denied your request. The Plan says the IRF admission is 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 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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cozaar. 
 
You asked the Plan to pre-approve Cozaar. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Cozaar.  
 
Benefits for Cozaar 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 the MyoPro Motion G device (CPT code L8702). 
 
You asked the Plan to pre-approve the device. You say that MyoPro is appropriate for the enrollee including 
for the duration and frequency and it is intended for permanent, daily functional restoration of an arm rendered 
chronically impaired and resistant to tried alternative rehabilitation techniques that have been offered to date. 
The Plan denied your request. The Plan says a review of current medical literature shows that these service(s) 
do not have a proven benefit and are considered experimental/investigational. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found records from the enrollee's actual treating provider do not clarify why the requested device is 
the most appropriate treatment for the enrollee's condition. In addition, provided records report left upper 
extremity spasticity severe enough to require Botox injections and a shoulder subluxation, which may be 
contraindications to use of the device. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G device (CPT code L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 5-zone therapeutic mattress. 
 
You asked the Plan to pre-approve a 5-zone therapeutic mattress. You say that the enrollee has stage 1 pressure 
ulcers on heel of foot and coccyx due to their current mattress. The Plan denied your request. The Plan says the 
5-zone therapeutic mattress (a commercial type of deluxe mattress) is not covered because it is not medical in 
nature and is regularly and primarily used by persons who do not have a specific medical need for them, so this 
request has been denied. 
 
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 5-zone therapeutic mattress. Our 
physician reviewer found there is no documentation that the 5-zone therapeutic mattress at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for the patient. Provided medical records do 
not document a medical provider's examination confirming a pressure ulcer on the trunk or pelvis as required 
by Medicare's LCD: Pressure Reducing Support Surfaces - Group 1 (L33830). In addition, the provided records 
do not confirm that the 5-zone therapeutic mattress meets the definition of durable medical equipment. As 
stated in the Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME 
MACs - A55426: "Supplier-produced records, even if signed by the treating practitioner, and attestation letters 
(e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment 
purposes. Templates and forms, including CMS CMNs, are subject to corroboration with information in the 
medical record. A prescription is not considered to be part of the medical record. Medical information intended 
to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated 
by information contained in the medical record. The beneficiary's medical record must contain sufficient 
documentation of the beneficiary's medical condition to substantiate the necessity for the type and quantity of 
items ordered and for the frequency of use or replacement (if applicable). The information should include the 
beneficiary's diagnosis and other pertinent information including, but not limited to, duration of the 
beneficiary's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc." 
 
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 5-zone therapeutic mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a 5-zone therapeutic mattress.