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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466 - Life2000 system). 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee no longer has active coverage with the Plan, ending September 30, 2022. 
 
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 the system. Our reviewer says that the 
requested system is not medically reasonable or necessary. Our physician reviewer found that the Life2000 
System is not medically necessary. This patient has dyspnea on exertion. Spirometry is consistent with severe 
restrictive lung disease. There is no diagnosis of chronic obstructive pulmonary disease (COPD), thoracic 
restrictive disease, or neuromuscular disease. This device is not a true ventilator, because it is not capable of 
providing full ventilatory support. It is designed to provide positive airway pressure during activity. There is inadequate evidence of efficacy in the treatment of any lung disease. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466 - Life2000 system).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require intensive rehabilitation and can not participate in or 
benefit from intensive rehabilitation. She has low endurance and low complexity of rehabilitation needs as she is primarily chronically deconditioned. There is no indication for frequent physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a specialist office visit and wrist x-ray 
provided on May 10, 2022, a specialist office visit, wrist x-ray, and splint application provided on May 17, 
2022, and specialist physician services provided on June 14, 2022, and June 16, 2022.  
 
 
 You asked the Plan to waive the cost share for a specialist office visit and wrist x-ray provided on May 10, 
2022, a specialist office visit, wrist x-ray, and splint application provided on May 17, 2022, and specialist 
physician services provided on June 14, 2022, and June 16, 2022. You say that you have never had to pay more 
than your insurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that enrollees have a $500  
deductible. Your contract with the Plan also clearly says that you must pay a $10 copayment for services 
obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physicians 
assistant or other non-physician health care professionals in a specialists office. 
 
You have been asked to pay $412.79 for specialist office visits, x-rays, a splint application, and a cast 
application. The record shows your deductible was not met prior to the processing of these appealed claims. A 
total of $204.52 was applied to your deductible for an office visit and an x-ray that was received on May 10, 
2022. A total of $188.27 was applied to your deductible for the physician services and x-ray that was received 
on May 17, 2022. Physician services fall within the physician/practitioner services benefit category. X-rays fall 
within the outpatient diagnostic testing benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible which applies to specialist physician services and x-
rays. This cost sharing is a contractual obligation that had not been met at the time the specialist physician 
services and x-rays was received on May 10, 2022, and May 17, 2022. 
 
You have been asked to pay a $10 copayment for each specialist physician service received on June 14, 2022, 
and June 16, 2022. 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.  
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 waive the cost share for specialist office visits, x-rays, and the cast application provided 
from May 10, 2022, to June 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab. 
 
You asked the Plan to pre-approve Denosumab. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Denosumab. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case there is no documentation of 
metastatic disease, pathologic fractures or compression fractures. The review has determined that the 
documentation does not support that the Denosumab is medically reasonable and necessary for the enrollee. 
The documentation does not support that the Denosumab is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Denosumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Denosumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital supplies and 
services provided on January 15, 2021, through January 30, 2021. 
 
You asked the Plan to pay an additional amount for the inpatient hospital supplies and services. You say that 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
these services are included in the room and board charge. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital supplies and services have not been met. Specifically, the documentation 
submitted includes an itemized bill summary. The items that have been denied with status code G are 
considered routine items and services and are not separately reimbursable. Therefore, we decided that the Plan 
does not have to pay an additional amount for the inpatient hospital supplies and services provided on January 
15, 2021, through January 30, 2021.
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 this 
enrollee was recently hospitalized after being found down at home. The enrollee was in acute respiratory 
failure and required intubation. There is a long smoking history and chronic obstructive pulmonary disease 
(COPD) is presumed.  A venous blood gas was consistent with severe hypercapnia. There are no arterial blood gases (ABG) done while stable to confirm chronic CO2 retention, although that seems likely. If the enrollee 
does have chronic CO2 retention, BiPAP with AVAPS during sleep is indicated. Medicare does not cover a 
home ventilator when used as BiPAP. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would benefit from skilled nursing services due 
to your medical complexity. The Plan denied your request. The Plan says you would be equally well served at 
an alternate level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. You do not require skilled 
nursing or therapy services on a daily basis. You do 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says you are requesting Procrit for an off-label, not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Procrit. Our reviewer says that Procrit 
is not medically necessary for this patient. Our physician reviewer found the requested use of Procrit in this 
case is not FDA-approved and its use is not supported for the patient's condition.  There is some data for its use 
if the patient is intolerant of high dose hydroxyurea, but it is not supported in the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has a history of hip fracture in February 2022 and was discharged home 
on 2/25/22. There is ongoing weakness. There are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 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. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollees status is stable and improving. The 
enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital, and there are no issues for which 
LTACH may offer a therapeutic advantage. 
 
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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is presently receiving appropriate services in the acute care setting. 
Continued care in the acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care 
such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lidocaine intravenous infusion injection provided to the 
enrollee on October 28, 2021. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says this code was not appropriate for the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J2001 is "Injection, lidocaine hcl for intravenous 
infusion, 10 mg." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the injection. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that procedure report documents 
"Medication injected: Zilretta Vial." J2002 would be reported for intravenous infusion. In this case, services 
were reported incorrectly. There is a more appropriate code to report for service provided. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a lidocaine intravenous infusion injection provided to the enrollee on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed (E0303). You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested heavy duty extra wide hospital bed (E0303). 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0303) is 
covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight 
is more than 350 pounds but does not exceed 600 pounds. In this case, the file shows that the enrollee's weight is less than 350 pounds. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra 
wide hospital bed (E0303).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Yervoy. 
 
You asked the Plan to pre-approve Yervoy. You say that this drug is medically necessary for the patient. The 
Plan denied your request. The Plan says that this drug is being requested for an off-label, not medically-
accepted use. 
 
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 Yervoy. Our reviewer says that Yervoy 
is medically necessary and appropriate for this patient. Our physician reviewer found Yervoy is currently FDA-
approved for the patient's diagnosis but usually requires oxaliplatin or irinotecan as well as fluorouracil.  The 
use of this drug is supported in the major compendia for the enrollee's condition. It is considered safe and 
effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy have been met. Therefore, we decided that the Plan has to pre-approve 
Yervoy.  
 
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet coverage 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is too ill to participate in or benefit from intensive rehabilitation. 
Admission to an IRF is indicated when the enrollee is able to participate in and benefit from intensive rehabilitation. Per records the enrollee can not participate in intensive rehabilitation. 
 
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.