Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet all the required Medicare criteria for admission 
to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the 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 sepsis, pulmonary embolism and rhinovirus infection. 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 the IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician attendance and supervision of hyperbaric 
oxygen therapy, per session (99183) and hyperbaric oxygen under pressure, full body chamber, per 30-minute 
interval (G0277). You asked the Plan to pre-approve hyperbaric oxygen therapy (HBOT). You say that there is an emergent issue 
as more tissue will be lost. This may lead to more surgeries. This therapy would help increase tissue viability in 
an enrollee with a compromised flap. The Plan denied your request. The Plan says the requested therapy is not 
medically necessary. Records do not show a diagnosis of acute peripheral ischemic, compromised skin graft, or 
refractory osteomyelitis. The medical records support that the enrollee has chronic peripheral vascular disease 
for which this service is not covered. 
 
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 hyperbaric oxygen therapy (HBOT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee was seen in the wound care clinic on March 7, 2023, with 
concern for discoloration at a surgical suture site. There was no indication of a skin graft or flap performed 
with the transmetatarsal amputation. The provider has indicated "flap failure" however no investigation 
including further vascular evaluation or wound exploration has been documented. The records do not show a 
diagnosis of acute peripheral ischemic, compromised skin graft, or refractory osteomyelitis. The medical 
records support that the enrollee has chronic peripheral vascular disease for which this service is not covered. 
The review has determined that the enrollee does not meet criteria for coverage of hyperbaric oxygen therapy. 
The HBO therapy is not medically necessary 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 hyperbaric oxygen therapy (HBOT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve physician attendance and supervision of hyperbaric oxygen therapy, 
per session (99183) and hyperbaric oxygen under pressure, full body chamber, per 30-minute interval (G0277).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49405-59 x2 billed for date of service 
September 27, 2022. 
 You asked the Plan to pay for procedure code 49405-59 x2. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 49405-59 x2 is 2. The MAI value for this code is 3. You billed 4 units of 
this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 49405-59 x2 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 49405-59 x2 billed for date of service September 
27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a urine flow test provided on September 12, 
2022. 
 
You asked the Plan to waive the copayment for the urine flow test. You say that you believe there is a mistake 
with this charge. 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 $30 
copayment for each Medicare-covered non-radiological diagnostic service.  
 
You have been asked to pay a $30 copayment for the urine flow test. This item/service falls within the 
outpatient diagnostic testing and therapeutic 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 
copayment for a urine flow test provided on September 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialized lower limb prosthetic cover (L5962) and 
additional feature (L5999). 
 
You asked the Plan to pre-approve the items. You say that this is being requested to protect internal 
components from impact and to protect prosthesis from dust and contaminants. The Plan denied your request. 
The Plan says the records provided do not indicate that the enrollee is exposed to harsh conditions or engages 
in extraordinary activities that require extra protection from a specialized prosthetic cover. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided medical records from the patient's treating physician/medical provider do not support 
that the patient will be exposed to such an unusually harsh and difficult environment that the standard 
prosthetic cover would be inadequate for his needs. Provided medical records from the patient's treating 
physician/medical provider do not support that the additional feature (L5999) meets all Medicare criteria for 
medically reasonable and necessary for the patient. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a specialized lower limb prosthetic cover (L5962) and additional feature (L5999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup for sleep apnea machine (A9270). 
 
You asked the Plan to pre-approve a battery backup for sleep apnea machine. You say that the item should be 
covered. The Plan denied your request. The Plan says this is not a covered item. 
 
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 sleep apnea machine (A9270).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on July 22, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance service was not medically necessary. Our 
physician reviewer found the enrollee was transported from a nursing home where she resides to a routine 
physician office visit. The record indicates that the enrollee was transported via stretcher. The record does not 
indicate that the enrollee's clinical condition is such that other methods of transport, such as stretcher van, are 
contraindicated or that the expertise, services and life-sustaining equipment that only a fully equipped 
ambulance can provide was required.  
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation. We decided that the Plan does not 
have to pay for the intraoral radiographic images.  
 
You asked the Plan to pay for a comprehensive oral evaluation (D0150) and intraoral radiographic images 
(D0230) provided on November 22, 2022. You say that you were told the provider was an in-network provider. 
The Plan says that your benefit for the requested items or services had been exhausted. 
 
We decided that the Plan has to pay for the comprehensive oral evaluation.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Your contract with the Plan 
clearly states a comprehensive oral evaluation is covered 1 procedure code every 3 calendar years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not clearly disclosed that the benefit for oral evaluations is limited to 1 procedure code every 365 days. The 
Plan contract says that the enrollee has coverage for one oral evaluation procedure code every calendar year. 
There is no evidence that the Plan has paid for an oral evaluation procedure code in the 2022 calendar year. 
Documentation shows the Plan paid for a comprehensive oral evaluation for the calendar year of 2019. 
Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation provided on November 
22, 2022. 
 
We also decided that the Plan does not have to pay for the intraoral radiographic images. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral radiographic images was exhausted on date of service of November 22, 
2022. Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images provided 
on November 22, 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: 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 admission to IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care 
such as skilled nursing facility (SNF), home with home health services or home with outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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: 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 you require an IRF admission to regain your 
independence. 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 you do 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 or occupational therapy, there is no documented need for intensive rehabilitation services. 
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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
(D4266 x 2), and osseous surgery one to three contiguous teeth or tooth bounded spaces per quadrant (D4261 x 
2). 
 
You asked the Plan to pre-approve codes D4266 and D4261. You say that you were told by the Plan that 
periodontic surgery would be covered, 60% by you and 40% by the Plan. The Plan denied your request. The 
Plan says these services are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration - resorbable barrier, per site (D4266 x 2), and osseous surgery one to three 
contiguous teeth or tooth bounded spaces per quadrant (D4261 x 2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (64633, 64634) 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the member did not have 80% pain relief of primary pain after 
first procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, 
there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of 
relief being consistent with the agent used) for a second to be considered medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiofrequency ablation have not been met. Specifically, the documentation submitted indicates 
the member did not have 80% pain relief of primary pain after first procedure. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation (64633, 64634)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
(power tilt) and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. You 
say that the motorized wheelchair is needed due to hemiparesis of right-side post stroke. The Plan denied your 
request. The Plan says the enrollee does not have medical need for single option included with K0856 group 3 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with single power option 
may be covered if certain 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 a group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the enrollee does not meet the Medicare criteria for the 
requested group 3 power wheelchair with single power option. Our physician reviewer found the ability of the 
enrollee's care givers to use a manual wheelchair is not addressed. The enrollee cannot use the power 
wheelchair for most of the activities of daily living as she cannot transfer, bathe or dress without assistance. 
There is insufficient evidence a power wheelchair is necessary to assist the enrollee with mobility-related 
activities of daily living. 
 
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 group 3 power wheelchair with single power option and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
single power option (power tilt) and accessories.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Pembrolizumab. 
 
You asked the Plan to pre-approve Pembrolizumab. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says that the use of Keytruda for uterine cancer with 
unknown microsatellite instability, unknown mismatch repair deficient, or unknown tumor burden is not FDA 
approved or listed in the Medicare approved sources. 
 
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 Pembrolizumab. Our reviewer says that 
the criteria for coverage have been met. Our physician reviewer found Lenvatinib plus Pembrolizumab showed 
promising antitumor activity in patients with advanced endometrial carcinoma who have experienced disease 
progression after prior systemic therapy, regardless of tumor microsatellite instability (MSI) status. The 
combination therapy had a manageable toxicity profile. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab have been met. Therefore, we decided that the Plan has to pre-
approve Pembrolizumab.  
 
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.