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

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage of this device have not been 
met. 
 
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 shows 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 power operated vehicle.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation (T2003) provided on January 
22, 2022. 
 
You asked the Plan to pay for non-emergency transportation. You say that you want the Plan to pay for this 
service. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for non-emergency transport 
services.  
 
The services you have asked the Plan to pay for are non-emergency transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergency transportation (T2003) provided on January 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (CPT code Q5106). 
 
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 accepted use of this drug for the enrollee's condition requires recent 
Hemoglobin (Hgb) level less than or equal to 10.0 g/dL or Hematocrit (HCT) less than 30%. The Plan states 
the enrollee does not meet these requirements. The Plan states the information they have says the enrollee's 
hemoglobin is greater than 10.0 g/dL and hematocrit is over 30%. 
 
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 the medication. Our physician reviewer 
found the review has determined that the requested use of Retacrit is not FDA approved for the enrollees 
diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a 
Centers for Medicare & Medicaid Services (CMS) approved medical journal. 
 
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 Retacrit (CPT code Q5106).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for LTACH 
care have not been met. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 needs IRF level of care. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's clinical condition meets full IRF 
criteria which the lower level of care in skilled nursing cannot provide. The Plan denied your request. The Plan 
says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that the arterial blood gas contained in 
the enrollee's record shows a pO2 of 100 and a PCO2 of 42. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary.  This enrollee has severe chronic obstructive 
pulmonary disease (COPD) but does not have chronic carbon dioxide (CO2) retention and did not retain CO2 
during a recent acute exacerbation. Therefore, respiratory support during sleep is 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you are being seen at the facility 
by other specialists due to your cancer diagnosis and you want to be able to continue being seen for continuity 
of care. The Plan denied your request. The Plan says there are in-network providers that can perform the 
services you need. 
 
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 consultation to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the enrollee is living in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair and accessories is being requested for use in a SNF. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve robotic pyeloplasty surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve surgical service. You say that the enrollee's urologist determined that the 
enrollee needs a higher level of care for treatment. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee 
can be treated within the Plan network. 
 
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 
robotic pyeloplasty surgery to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. You say that this is medically necessary. The Plan denied your 
request. The Plan says this use is not supported. 
 
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 Enhertu. Our reviewer says that the 
requested use of Enhertu is not supported. Our physician reviewer found Enhertu FDA-approved for the 
enrollees diagnosis only as second-line therapy. This use is also not supported by the major drug compendia or 
by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression 
(PILD) procedure (0275T). 
 
You asked the Plan to pre-approve a PILD procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of the requested 
service have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PILD will be covered when provided in a clinical 
study through CED for beneficiaries with LSS who are enrolled in an approved clinical study 
 
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 PILD procedure. Our reviewer says 
that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found 
that detailed documentation is not evident in the case record regarding the enrollee participating in a medical 
study. There is no clinical evidence of substantiated neurogenic claudication, nor radiographic evidence of 
significant spinal stenosis. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. 
 
 
  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 PILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a PILD procedure (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that your shower chair is damaged. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services (A0428, A0425) 
provided on January 24, 2022. 
 You asked the Plan to pay for non-emergency ambulance services. You say that the Plan should pay because 
the enrollee went into hospice after the service took place. The Plan denied your request. The Plan says original 
Medicare is responsible for payment under the fee-for-service benefit. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for non-emergency ambulance services (A0428, A0425) 
provided on January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that Intracept is medically necessary and supported by 
strong science. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because Intracept is 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services have not 
been met. 
 
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 manual wheelchair to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses provided on March 5, 2021. 
 
You asked the Plan to pay for contact lenses. The Plan denied your request. The Plan says Medicare denies a 
claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the 
date the services were furnished. The claim was received on April 25, 2022, which is past the allowed  
12-month timeframe. The Plan does not have any evidence or proof the claim was submitted before the timely 
filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for contact lenses was not filed until April 25, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for contact lenses provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the calibrator solution billed for services provided from 
February 24, 2022, to May 14, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code 
remains not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order or relevant medical records which support the billed 
amount for the supplies provided in this case. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the calibrator 
solution billed for services provided from February 24, 2022, to May 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code (s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the intracept procedure is for treatment 
of the enrollee's back pain. The Plan denied your request. The Plan says unproven and not medically necessary 
procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (CPT code (s): 64628 and 64629).