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

 
We decided that the Plan does not have to pre-approve eight (8) additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
to get to your dialysis appointments three times per week. The Plan denied your request. The Plan says you 
have exhausted the maximum benefit of 48 one-way trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve eight (8) additional routine transportation trips (A0120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need to see the requested provider to 
verify why you are having strokes and to see if treatment is needed. The Plan denied your request. The Plan 
says you are requesting an additional 73 miles for a total of 123 miles and your benefit only allows 50 miles. 
The Plan also says you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when The Plan covers up to 100 one-way trips and each one-way 
trip must not exceed 50 miles of driving distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has moderate to severe 
urinary incontinence. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Acre Carbon Ultralight Rollator walker. 
 
You asked the Plan to pre-approve these services. You say that this walker is foldable and easier to put in your 
car. The Plan denied your request. The Plan says the services are not covered for use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an Acre Carbon Ultralight Rollator walker.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation trips for your cancer treatment. The Plan denied your request. The Plan says your benefit only 
allows 60 trips per year. You have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips (A0120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide an additional 120 routine transportation trips for 2022. 
 
You asked the Plan to provide additional transportation. You say that you need additional transportation to get 
to and from your dialysis appointments. The Plan denied your request. The Plan says your benefit covers a 
maximum of 48 routine trips per year. Additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide an additional 120 routine transportation trips for 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records report the enrollee has 
diagnoses of migraine with aura, not intractable, without status migrainosus and chronic migraine without aura. 
The records do not document the patient has at least five attacks fulfilling the following criteria: headache 
attacks lasting 4-72 hours (when untreated or unsuccessfully treated); headache has at least two of the 
following: unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing 
avoidance of routine physical activity (e.g., walking or climbing stairs) as required by the Medicare rules. The 
criteria are not met and the Botox is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophageal balloon distension study and breath test. 
 
You asked the Plan to pre-approve an esophageal balloon distension study and breath test. You say that you 
have had persistent diarrhea ever since your past Nissen Fundoplication a year ago and you have diarrhea ten 
times daily. You say that your doctor ordered for a Trio Smart Breath test to help diagnose small intestinal 
bacterial overgrowth. The Plan denied your request. The Plan says the hydrogen breath test for small intestine 
bacteria overgrowth is excluded from Medicare coverage. 
 The Plan must follow Medicare rules. Medicare rules say that Lactulose breath hydrogen for diagnosing small 
bowel bacterial overgrowth and measuring small bowel transit time is excluded from coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an esophageal balloon distension study and breath test have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an esophageal balloon distension study and breath test.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a low dose computed tomography (CT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of a 30 year smoking history. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
been followed in the past for a stable 4mm right pulmonary nodule now considered benign due to stability over 
several years He has a smoking history with the note mentioning he smoked 1 pack per day (unknown 
duration) and quit in 2001 (21 years ago).  As such he does not qualify for LDCT for lung cancer screening. 
Specifically a smoking history of at least 30 pack years as well as currently smoking or having quit within the 
past 15 years are factors Medicare considers necessary to qualify for LDCT for the purpose of lung cancer 
screening. The patient has a known right pulmonary nodule which has been classified as benign due to stability 
for over 2 years. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a low dose computed tomography (CT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 94761. The Plan denied your request. The Plan says procedure 
code 94761 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. As there are 
other services payable under the physician fee schedule billed on the same date by the same provider, these services are bundled into the physician services for which payment has been made. This means that procedure 
code 94761 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 94761 billed for date of service June 15, 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 you need physical therapy to be able to get around 
on your own. The Plan denied your request. The Plan says you do 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. 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. 
 
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 Entyvio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no indication that the plan's required drugs 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services to regain your mobility after 
your surgery. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup for a CPAP machine (A9270). 
 
You asked the Plan to pre-approve the battery backup. You say that the battery was medically necessary. The 
Plan denied your request. The Plan says power generating equipment is not considered medical in nature and is 
non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery backup for a CPAP machine (A9270).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ondansetron tablet. 
 
You asked the Plan to pre-approve Ondansetron. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not, as prescribed, among the types which are 
covered by Medicare Part B because the case record shows that the self-administered drug will not be used as a 
full therapeutic replacement for the intravenous anti-emetic drugs that would have otherwise been administered 
at the time of the chemotherapy treatment. Therefore, we decided that the Plan does not have to pre-approve 
treatment with Ondansetron tablet.  
 
Benefits for Ondansetron 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brovana (aformoterol tartrate) for use with a nebulizer. 
 
You asked the Plan to pre-approve the requested Brovana. You say that it is felt that the requested drug should 
be approved. The Plan denied your request. The Plan says there has not been a failure of the preferred drug and 
no reason it would not be as effective as Brovana. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested Brovana. Our reviewer 
says that the requested medication is not considered reasonable and necessary based on step therapy rules. Our 
physician reviewer found the enrollee is a 63-year-old female with a diagnosis of chronic obstructive 
pulmonary disease and asthma. Treatment with nebulized arformoterol tartrate has been requested. The health 
plan denied coverage for the nebulized arformoterol tartrate as the plan requires a trial of formoterol before 
they will approve the requested drug.  
 
Based on the medical records provided there is no indication that the enrollee has tried and failed the required 
drug. There is also no indication that the plan's 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 the requested Brovana have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Brovana (aformoterol tartrate) for use with a nebulizer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee needs this service. The 
Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the documentation does not indicate that the enrollee 
has a tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes). Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 undergoing treatment at an acute care hospital (ACH) after emergency 
surgery for a perforated bowel, complicated by abdominal bleeding. He remains on a ventilator, is bedbound, 
and is receiving intravenous (IV) nutrition. There is no evidence that the enrollee requires services that are not 
available at the current setting. As LTACHs and ACHs are licensed to provide the same level of care, there is 
no advantage in transferring the enrollee to the LTACH. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure improved the quality of 
life of patients suffering form vertebrogenic low back pain. The Plan denied your request. The Plan says there 
are not enough studies that show that the Intracept procedure is safe and effective. The Intracept technique has 
not been shown to improve the health of patients with the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at 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 (64629, 64628).