Persius/hicric huggingface dataset:
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says IRF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID-19 pneumonia and atrial fibrillation. The enrollee's medical problems are stable. 
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 this 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that the clinical information provided supports the 
need for the requested drug. The Plan denied your request. The Plan says this oral medication is covered under 
the pharmacy benefit and is not covered under the Medicare medical benefit. The Plan says that the enrollee 
does not have a pharmacy benefit with them. 
 
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 Methotrexate.  
 Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard wheelchair and leg rests rendered on December 
1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 
pay for the standard wheelchair and leg rests rendered on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pharmacogenetic testing provided May 24, 2021 
 
You asked the Plan to pay for the laboratory service. You say that you believe that the treatment sought was 
medically necessary. The Plan denied your request. The Plan says service is not covered by Medicare. 
 
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, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for molecular pharmacogenetic testing provided May 24, 2021
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional routine transportation trips. 
 
You asked the Plan to pre-approve the 10 additional routine transportation trips. You say that you need to see 
an orthopedic doctor because you have a problem with your long spine bar. You say that it is out of place and 
that you cannot walk because of it. The Plan denied your request. The Plan says the requested number of trips 
exceeds your benefit allowance. 
 
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 24 one-way routine transportation trips per year.  
 We looked at your request, the records in the case file, and the rules. The records show that, at the time of your 
appeal request, the Plan had covered 23 one-way routine transportation trips in the 2022 calendar year. Based 
on this information, we decided that the number of trips being requested would exceed the Plan maximum 
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
10 additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of discs in the neck. 
 
You asked the Plan to pre-approve replacement of discs in the neck. You say that you have been dealing with 
pain for over 1 year and have gotten worse over the last 6 months. You say that your pain is now radiating 
down both shoulders and your back, and you now have to walk bent over. You say that you have tried physical 
therapy, acupuncture, chiropractic care, and 3 different kinds of medication with no relief. You say that you are 
having lots of trouble lifting your left arm The Plan denied your request. The Plan says the requested surgery is 
not proven and is not considered medically necessary. 
 
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 replacement of discs in the neck. Our 
reviewer says that replacement of discs in the neck is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the imaging shows posterior degeneration of the facets at multiple levels in 
this elderly patient. Multilevel disc replacement surgery is not medically needed and not FDA approved for this 
extensive degenerative condition. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of replacement of discs in the neck have not been met. Therefore, we decided that 
the Plan does not have to pre-approve replacement of discs in the neck.
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 you sleep sound, and you are unaware 
of the leakage of urine that saturates your sheets and protective mattress. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdomen x-ray rendered on October 23, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the abdomen x-ray rendered on October 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips. 
 
You asked the Plan to pre-approve the routine transportation trips. You say that you have had previous issues 
with transportation and not being able to go to appointments. You say that you recently had surgery and have 
had complications, which is why you have an appointment scheduled for August 1, 2022. The Plan denied your 
request. The Plan says the enrollee has exceeded the limits set in the subscriber agreement. 
 
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 each one-way trip does not exceed 50 miles of driving distance. 
 
We looked at your request, the records in the case file, and the rules. The records show that the location you are 
requesting routine transportation to is more than 50 miles from your home address. Based on this information, 
we decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox injection services. 
 
You asked the Plan to pre-approve Botox injection services. You say that a botulinum toxin injection into the 
pyorus sphincter for the enrollee's gastroparesis for his clinical care is appropriate and should be covered by the 
Plan. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 Botox injection services. Our reviewer 
says that the criteria for coverage have been met. Our physician reviewer found the enrollee is an 82-year-old 
man who previously underwent resection of cancer at the gastroesophageal junction. The enrollee does not 
have a lower esophageal sphincter, and reports vomiting in the morning or after eating, as well as nocturnal 
cough and heartburn. The enrollee has diagnoses of gastroparesis with Nausea with vomiting, unspecified. 
There is support in the medical literature for the endoscopic administration of Botox as an accepted 
intervention for the management of Gastroparesis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injection services have been met. Therefore, we decided that the Plan has 
to pre-approve Botox injection services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kesimpta. 
 
You asked the Plan to pre-approve Kesimpta. You say that the enrollee has symptoms that are not being 
controlled on the current medication. You say that the requested medication would benefit better symptom 
control and maximize daily function. The Plan denied your request. The Plan says the enrollee's plan does not 
have a Medicare part D benefit for separate pharmacy benefit. 
 
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 Kesimpta.  
 Benefits for Kesimpta 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: 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that 
the enrollee could receive care in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical management of an ankle fracture and was transferred to skilled nursing on February 
22, 2022, then discharged to skilled nursing on March 7, 2022. There is ongoing weakness. The enrollee's 
medical problems are stable. 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 this 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox injection services. 
 
You asked the Plan to pre-approve Botox injection services. You say that the best minimally invasive option 
for the enrollee is Botox injection of the lower esophagus. You say that this is their only option to provide the 
enrollee with symptom benefit and not risk potential malnutrition and the costs and consequences that would 
follow. The Plan denied your request. The Plan says that the requested Botox injection services are not 
reasonable and necessary at this time. 
 
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 Botox injection services. Our reviewer 
says that the criteria for coverage have been met. Our physician reviewer found the enrollee has a diagnosis of 
dysphagia due to hypercontractile esophagus, in addition to insulin requiring diabetes, hypertension, and 
obesity. An esophagram showed no obstruction, but the enrollee did have significant motility issues with 
multiple hypercontractile swallows and a pressurization pattern most consistent with EGJ outflow obstruction. 
The enrollee has been treated with Pantoprazole and Sucralfate twice daily. The use of Botox is supported by 
clinical research to treat hypercontractile esophagus and has been shown to offer symptomatic improvement. 
The documentation supports that Botox is reasonably expected to be safe and effective and otherwise 
reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injection services have been met. Therefore, we decided that the Plan has 
to pre-approve Botox injection services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit services provided on February 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit services. You say that it is the nursing facility's 
responsibility to obtain prior authorization. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home health visit services provided on 
February 10, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no data on a safe and effective 
dose of Xolair for the enrollee's weight and IgE level, due to insufficient data. The services are therefore 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 Xolair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99213) and the x-ray exam of ankle 
(73610) provided on March 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit and x-ray. You say that you assumed the visit would be 
covered because the visit a year ago was covered. The Plan denied your request. The Plan says the services 
were provided out-of-network and were not approved in advance. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient visit (99213) and the x-ray exam of 
ankle (73610) provided on March 7, 2022, by an out-of-network (OON) provider.