Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octreotide Acetate (J2354). 
 You asked the Plan to pre-approve Octreotide Acetate. The Plan denied your request. The Plan says the 
information says that the enrollee is in a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Octreotide Acetate as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve Octreotide Acetate (J2354).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator. 
 
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that a spinal electrical osteogenesis stimulator is only 
covered for failed fusion surgeries where a minimum of 9 months has elapsed since the last surgery We looked at the file and Medicare rules. In this case, 9 months have not passed since your fusion surgery. 
Based on this information, we decided that Medicare rules for coverage of a spinal electrical osteogenesis 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal 
electrical osteogenesis stimulator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for ambulance services provided on June 9, 
2021. 
 
You asked the Plan to waive the cost sharing for ambulance services. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The Plan contract also says that there is a $290 deductible which 
applies to certain items and services. The Plan deductible applies to ambulance services.  The enrollees contract with the Plan also clearly says that enrollees must pay 20% coinsurance after the 
deductible has been met for ambulance services.  
 
The item or service you asked the Plan to waive the cost sharing for falls within the Ambulance Services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $290 
deductible which applies to ambulance services. The enrollees remaining deductible amount of $160.15 was 
applied to this service first. The enrollees deductible has now been fully met. 
 
After the deductible is met, the plan will share the cost of any remaining balance for the service. The remaining 
balance after the deductible was applied is $271.08 ($431.23 original allowed amount - $160.15 deductible = 
$271.08 remaining allowed amount). You have been asked to pay $54.22, which is 20% of the remaining 
allowed amount for the ambulance service (A0427) ($271.08 allowed amount x 20% coinsurance = $54.22). 
You have also been asked to pay $26.09, which is 20% of the allowed amount for ambulance services (code 
A0425) ($130.47 allowed amount x 20% coinsurance = $26.09). The enrollee has been asked to pay a total of 
$240.46 for ambulance services ($160.15 deductible + $54.22 coinsurance + $26.09 coinsurance = $240.46). 
Ambulance services falls within the Ambulance Services benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the cost sharing for ambulance services provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 Sensor. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member is not adjusting their insulin doses based on their blood 
glucose readings 
 
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 require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a Dexcom G6 Sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in average volume-
assured pressure support (AVAPS) mode that could be delivered by BiPAP is not covered. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. The enrollee has chronic respiratory failure 
due to COPD and obstructive sleep apnea syndrome (OSAS). It was reported that he was non-compliant with 
prescribed BiPAP. A portable home mechanical ventilator set in AVAPS was requested.  However, based on the provided documentation, the patient could safely use BiPAP in AVAPS mode for their 
needs. There was no report that suggested that the BiPAP machine would not provide the same effectiveness 
based on the patient's needs as he required only BiPAP support during a recent hospitalization. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Neuromuscular stimulator, electronic shock unit 
(NMES) (E0745). 
 
You asked the Plan to pre-approve a NMES. You say that you would like this item and feel as though it should 
be covered. The Plan denied your request. The Plan says the records do not indicate any spinal cord injury and 
they also do not indicate any muscle atrophy due to disuse. There is no indication from any of your providers 
that this device is felt to be medically necessary or appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that NMES involves the use of a device which 
transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. There are two 
broad categories of NMES. One type of device stimulates the muscle when the patient is in a resting state to 
treat muscle atrophy. The second type is used to enhance functional activity of neurologically impaired 
patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a NMES have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Neuromuscular stimulator, electronic shock unit (NMES) (E0745).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zarxio. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug would be deemed a routine cost of a clinical trial covered by the 
Medicare Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Zarxio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. You say that there is sufficient science published in peer-reviewed 
publications supporting that this requested procedure is safe and effective. The Plan denied your request. The 
Plan says the requested procedure is considered experimental and 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 an Intracept procedure. Our reviewer 
says that an Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. There are no formal imaging reports provided for review of the lumbar spine. 
There is a computed tomography (CT) and x-ray noted on the August 13, 2021, exam. However, the 
radiologist's read is not provided. In this case, there were/are also multiple plausible pathologic sources of significant pain generation. The noted midline pain radiating down the bilateral lower extremities to the 
buttocks (and intact neurologic exam) were/are all non-specific to any pathologic entities. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  Your medical problems are stable. You do not have 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 do have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
Additionally, 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Clonazepam tablet 0.5mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B 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 Clonazepam tablet 0.5mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service July 12, 2020, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 home ventilator. You say that you have been 
overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code. You are prescribed this for use as bilevel positive 
airway pressure (BiPAP) which should be coded as E0471, which is a much lower monthly payment and would 
become yours after a certain number of payments. You state that due to code E0466 you are being charged a 
higher monthly payment and never obtain ownership of the device. You feel that you should only be required 
to pay what would be owed for the E0471 code since these are the only features of the device that you use. The 
Plan denied your request. The Plan says you have been assessed the correct cost sharing for this device based 
on your contract. 
 
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 20% 
coinsurance for durable medical equipment and related supplies.   
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment and related supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the rental charges for the Trilogy 100 home ventilator for date of service July 12, 2020, billed with 
code E0466.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service June 12, 2020, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 home ventilator. You say that that you have 
been overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code. You are prescribed this for use as bilevel positive 
airway pressure (BiPAP) which should be coded as E0471, which is a much lower monthly payment and would 
become yours after a certain number of payments. You state that due to code E0466 you are being charged a 
higher monthly payment and never obtain ownership of the device. You feel that you should only be required to pay what would be owed for the E0471 code since these are the only features of the device that you use. The 
Plan denied your request. The Plan says you have been assessed the correct cost sharing for this device based 
on your contract. 
 
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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment and related supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the rental charges for the Trilogy 100 home ventilator for date of service June 12, 2020, billed with 
code E0466.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine dental services. 
 
You asked the Plan to pre-approve the routine dental services. The Plan denied your request. The Plan says 
these services are not covered benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve routine dental services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. You say that the requested drug is medically reasonable and 
necessary for the enrollee's condition. 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 Granix. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Nivestym and Zarxio before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
would likely be less effective and/or likely have adverse effects for 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 Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services should be paid because you do not 
have a contract agreement in place showing that these services are included in the dialysis rate. The Plan denied 
your request. The Plan says payment for lab services are not separately payable from the end-stage renal 
disease prospective payment system (ESRD PPS) payment/ 
 
The Plan must follow Medicare rules. Medicare rules say that ll lab services furnished to individuals for the 
treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System (PPS) and 
are not paid separately. However, a patient's doctor may order a lab test that is typically included in the ESRD 
PPS payment but for reasons other than the treatment of ESRD.  When this occurs, the provider may bill 
separately for these lab services using the AY modifier.  The AY modifier serves as an attestation that the 
service is medically necessary but not being used for the treatment of ESRD.   
In this case, you billed lab services that you typically be part of the ESRD PPS payment.  You did not append 
modifier AY to the claim to indicate that the lab services you provided were not for the treatment of ESRD. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on August 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that you have already undergone 4 sessions of epidural steroid 
injections in the past 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that ESIs are limited to a maximum of four (4) 
sessions per spinal region in a rolling twelve (12) month period.  
 
We looked at the file and Medicare rules. The file indicates you have had four sessions of ESIs within the last 
rolling 12 month period. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural 
steroid injection (ESI).