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

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0842) and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the Group 2 PWC and accessories are 
not medically necessary. 
 
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.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the provided 
records document that the enrollee is independent with feeding thus indicating he has adequate upper extremity 
strength and function to operate the wheelchair's power options with their own switches. The provided records 
do not support that the enrollee is high risk for skin breakdown (he can transfer with supervision and walk short 
distances with a walker), has a history of pressure ulcer(s), or has had skin flap surgery. The records do not 
document the enrollee performs bladder self-catheterization or that the enrollee has increased muscle tone or 
spasticity. Therefore, the multiple power options (power tilt/recline and power elevating leg rests) and 
expandable controller/harness and electronic connection do not meet criteria for coverage. As the wheelchair 
base does not meet criteria for coverage, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 2 power wheelchair (K0842) and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bevacizumab-Awwb. 
 
You asked the Plan to pre-approve Bevacizumab-Awwb. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare 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 Bevacizumab-Awwb. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of metastatic stage IV ovarian cancer. The Food and Drug Administration has not 
stated that the requested drug, as prescribed, is indicated for the enrollee's condition. The Medicare approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug, as prescribed, in 
the enrollee's specific clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Bevacizumab-Awwb have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Bevacizumab-Awwb.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that you are an existing patient with this physician. The Plan denied your request. The Plan 
says you must use network providers to get your medical care and services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 30, 2022, to 
October 3, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that these services could have been provided at an 
observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was a then 67-year-old female with a history of diabetes mellitus, hypertension, 
Atrial fibrillation, gastroesophageal reflux disease, and low back pain who presented to the emergency room on 
September 30, 2022, with weakness and dehydration. The evaluation revealed evidence of a urinary tract 
infection. She was treated with IV fluids and antibiotics and admitted to the medical floor. The record showed 
that at the time of inpatient admission, the admitting physician reasonably expected that the patient's necessary 
hospital care (including earlier emergency room and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 30, 2022, to October 3, 2022.  
 
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 pre-approve physician's services to be provided by the requested 
out-of-network orthopedic surgeon. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
orthopedic surgeon. You say that you have seen providers at this facility since you were a small child. You say 
had Polio and that the in-network providers do not have the experience to treat your condition because of the 
previous Polio diagnosis. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network orthopedic surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network outpatient mental health 
services provided from September 14, 2022, to October 12, 2022. 
 
You asked the Plan to waive the coinsurance for mental health services. You say that you were unaware there 
would be a coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for each out-of-network outpatient mental health service.  
 
You have been asked to pay a total of a $160 coinsurance for four mental health services ($100 allowed amount 
x 40% coinsurance = $40 coinsurance for each date of service). This item/service falls within the out-of-
network outpatient mental health services 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 coinsurance 
for out-of-network outpatient mental health services provided from September 14, 2022, to October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there has been no non-invasive work-up, such as a stress test. The medical records 
provided do not support the rationale for this invasive imaging study. Guidelines do not support a need for 
cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epoetin Alfa (J0885). 
 
You asked the Plan to pre-approve the Epoetin Alfa. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says a trial of Retacrit is required before alternatives can be considered. 
 
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 Epoetin Alfa. Our reviewer says 
that Epoetin Alfa is not medically necessary. Our physician reviewer found the record does not show a trial of 
the plan preferred drug or any reason it would be unsafe or ineffective. 
 
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 Epoetin Alfa have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Epoetin Alfa (J0885).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the esophagogastroduodenoscopy (EGD) 
procedure and the diagnostic colonoscopy performed on October 27, 2022. 
 
You asked the Plan to waive the deductible for the esophagogastroduodenoscopy (EGD) procedure and the 
diagnostic colonoscopy. You say that you think that you were billed incorrectly. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that you must pay the full cost for covered services until you have paid the $750 
deductible, and the deductible applies to outpatient surgery services. 
 
 
 
 You have been asked to pay a $657 deductible for the esophagogastroduodenoscopy (EGD) procedure and the 
diagnostic colonoscopy ($283.64 + $373.36 = $657 deductible). The items or services you asked the Plan to 
waive the deductible for fall within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual 
obligation that had not been met at the time the esophagogastroduodenoscopy (EGD) procedure and the 
diagnostic colonoscopy were performed on October 27, 2022. Therefore, we decided that the Plan does not 
have to waive the deductible for the esophagogastroduodenoscopy (EGD) procedure and the diagnostic 
colonoscopy performed on October 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 2, 2022, to 
January 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 2, 2022, to 
January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power 
wheelchair and accessories would allow independence in mobility and participation in leisure and social 
interactions. You also say the power tilt and recline would allow for pressure relief and adjustment of hip angle 
to improve the enrollee's comfort and posture. The Plan denied your request. The Plan says the requested 
durable medical equipment (DME) in a skilled nursing facility (SNF) is not covered by Medicare or the Plan. 
 
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 or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat home sleep study test (hst) with type II portable 
monitor, unattended (G0398). 
 
You asked the Plan to pre-approve a repeat home sleep study. You say that this service is medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for a home sleep study. 
 
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 a repeat home sleep study. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has a longstanding diagnosis of obstructive sleep apnea 
and has been on continuous positive airway pressure (CPAP) for years. The enrollee is interested in exploring 
hypoglossal nerve stimulator (INSPIRE). There is no indication that the enrollee is having difficulty using the 
CPAP or has had return of the symptoms of obstructive sleep apnea. There is no data download for the 
enrollee's CPAP. The enrollee does not appear to meet the requirements of the INSPIRE device, because the 
enrollee does not have documented intolerance of CPAP. There is no concern about the diagnosis of 
obstructive sleep apnea, and there is no indication that CPAP is not meeting the enrollee's needs.  
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 repeat home sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat home sleep study test (hst) with type II portable monitor, unattended 
(G0398).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve varicose vein treatments (37766, 37765). 
 
You asked the Plan to pre-approve the varicose vein treatments. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that treatments for symptomatic varicose tributaries are 
either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
therapy. 
 
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 varicose vein treatments. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found in order for the stab 
phlebectomy to be considered medically necessary, the patient has to demonstrate lifestyle limiting symptoms 
that persist despite regular use of compression stockings 6 weeks after the saphenous reflux is treated. These 
criteria have not been met.  
 
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 varicose vein treatments have not been met. Therefore, we decided that the 
Plan does not have to pre-approve varicose vein treatments (37766, 37765).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a varicose vein treatment (36470). 
 
You asked the Plan to pre-approve the varicose vein treatment. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that treatments for symptomatic varicose tributaries are 
either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. 
 
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 varicose vein treatment. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found there is insufficient 
description of the patients symptoms following bilateral great saphenous vein ablation. There is no 
documentation relating any symptoms to varicose veins or conservative treatment. 
 
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 varicose vein treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a varicose vein treatment (36470).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 20, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the service was medically appropriate and 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on December 20, 2022.