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

 
We decided that the Plan has to pay for the ambulance transportation and advanced life support (ALS) services 
provided on August 25, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the diagnosis code reported was correct 
based on the patient condition and reason for transport. The Plan denied your request. The Plan says that a 
diagnosis code that is required by Medicare rules was not reported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial rationale is in regard to a required diagnosis not being reported 
on the claim. However, no copy of the claim was provided for review to confirm the diagnosis codes billed. In 
addition, the Plan provided no reference to any rule which would identify what diagnosis codes were "required" 
and not present. Without this documentation, the denial of payment is not justified. Therefore, we decided that 
the Plan has to pay for the ambulance transportation and advanced life support (ALS) services provided on 
August 25, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with a single power feature 
(K0835, E2359, E1002, E2311). 
 
You asked the Plan to pre-approve the group 2 power wheelchair with a single power feature. You say that this 
type of power wheelchair 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 a single power feature power wheelchair is covered 
when the beneficiary requires a drive control interface other than a hand or chin-operated standard proportional 
joystick or the beneficiary meets coverage criteria for a power tilt or a power recline seating system. 
  
  
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 group 2 power wheelchair with a 
single power feature. Our reviewer says that the requested power feature wheelchair is not medically necessary. 
Our physician reviewer found the requested chair exceeds the patient's medical needs. The documentation does 
not reveal that the patient uses a ventilator attached to a wheelchair, is at high risk for skin breakdown, uses 
intermittent catheterization or has objective evidence of spasticity that needs a power seating system for 
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 the group 2 power wheelchair with a single power feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with a single 
power feature (K0835, E2359, E1002, E2311).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation trips 
(A0100). 
 
You asked the Plan to pre-approve additional transportation trips. You say that the enrollee had surgery to 
amputate the right leg below the knee. The enrollees truck is too high to get in and out of due to the 
amputation. The enrollee needs a wheelchair accessible vehicle. The enrollees doctor has ordered physical 
therapy for six to eight weeks. The Plan denied your request. The Plan says once the enrollee has exhausted 20 
one-way trips, he is not eligible for any additional transportation trips until the beginning of the next year, 
which would be January 1, 2023. 
 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 20 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
seventeen (17) one-way transportation trips out of the allowed twenty (20) one-way trips approved. Once 20 
trips are used, the benefit will be exhausted. 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 additional non-emergent routine transportation trips (A0100).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve viscosupplementation of the knee. 
 
You asked the Plan to pre-approve viscosupplementation. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because no radiographic images have been submitted to confirm a diagnosis of osteoarthritis. 
 
The Plan follows Medicare rules. Medicare rules state that viscosupplementation of the knee is covered for a 
diagnosis of osteoarthritis when 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 viscosupplementation. Our reviewer 
says that the enrollee does not meet the Medicare criteria for viscosupplementation of the knee. Our physician 
reviewer found viscosupplementation will not be covered when the diagnosis is anything other than 
osteoarthritis, but the clinical diagnosis of osteoarthritis is not supported by radiological evidence. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of viscosupplementation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve viscosupplementation of the knee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that the Plan has approved these injections before, and 
you do not understand why they are being denied now. The Plan denied your request. The Plan says in order 
for this request to be eligible for coverage under your medical benefit, the medication must be supplied by your 
medical provider or medical facility. The Plan also says that your medical provider said the Durolane will be 
supplied by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. The Plan denied your request. The Plan says that the member has 
complete loss of joint space which does not meet criteria. 
 
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 Orthovisc. Our reviewer says that the 
elements of the coverage criteria are satisfied, and the requested service is recommended. Our physician 
reviewer found that the record indicates the enrollee has a diagnosis of osteoarthritis of the knee confirmed by 
x-ray imaging. The record also indicates the enrollee has failed simple analgesics and conservative non-
pharmacologic therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have been met. Therefore, we decided that the Plan has to pre-
approve Orthovisc.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arm compression garments for the enrollee. 
 
You asked the Plan to pre-approve the garments. You say that this is medically necessary. The Plan denied 
your request. The Plan says this does not primarily serve a medical purpose. 
 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 garments. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has lymphedema to the upper extremity and has requested a compression garment 
(sleeve/glove) for treatment of her medical condition. The nature of this item does not constitute durable 
medical equipment, as it cannot be used by successive patients. It is not considered actually durable. 
 
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 garments have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arm compression garments for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on July 6, 2021 to August 
26, 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 claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the correct TOB 
code. Therefore, we decided that the Plan does not have to pay for the home health services rendered on July 6, 
2021 to August 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee needs Eliquis. The Plan denied your 
request. The Plan says Eliquis is a self-administered drug, and is not covered for the enrollee's condition by 
Medicare Part B. 
 
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 Eliquis.  
 
Benefits for Eliquis 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen handling services rendered on April 5, 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 procedure code 99000 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99000 (handling and/or conveyance of 
specimen for transfer from the office to a laboratory) has a status indicator of B and no separate Medicare 
payment. Therefore, we decided that the Plan does not have to pay for the specimen handling services rendered 
on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on August 30, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this test is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing must be reported with 
the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. In this case, the testing was not reported with an appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on 
August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that this is medically necessary. The 
Plan denied your request. The Plan says that there is no indication that you require home assisted ventilation 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home mechanical ventilator. Our 
reviewer says that that a home mechanical ventilator is not medically reasonable and necessary. You were 
recently hospitalized with lethargy and acute hypercarbic respiratory failure thought to be due to excess 
sedating medications. You have severe obesity, and obesity-hypoventilation syndrome is suspected. 
 There is no diagnosis for which Medicare covers a home ventilator. There is no arterial blood gases (ABG) 
done while stable as an outpatient to confirm chronic CO2 retention. Our physician reviewer found that your 
condition does not meet Medicare criteria for a home mechanical ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 9, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the records provided support the need for 
the requested item. You say that you have been in the hospital waiting and they will not let you leave unless 
you have this requested item. The Plan denied your request. The Plan says there is not compelling rationale 
submitted that supports the use of a home mechanical ventilator to deliver the assistance needed rather than bi-
level positive airway pressure (BiPAP) with back up rate and average volume-assured pressure support 
(AVAPS.) 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that a portable ventilator is not medically necessary. Our physician reviewer found the enrollee was given BiPAP after a previous hospitalization but had not been 
using it.  There is no evidence of BiPAP failure at home because it has not been used, and there is no 
documentation of persistent hypercapnea at home, while stable and using BiPAP consistently. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare 
due to insufficient evidence of efficacy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure remains experimental. More research is needed. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these services. 
 
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 the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hand controls. 
 
You asked the Plan to pre-approve the controls. You say that this will help control the gas and brakes of a 
vehicle. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 hand controls.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the thorax for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the guidelines recommend a repeat CT in two years, and not in one year. 
 
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 the enrollee has a 
couple of ground glass and semi-solid nodules measuring less than 6mm in diameter. They have been stable 
since October 2019, as of 2/11/21. The Fleischner Society guidelines of 2022 indicate that surveillance in this 
scenario is indicated at 2 and 4 years provided prior stability. These guidelines would indicate a surveillance 
CT is appropriate in February 2023. 
 
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 computed tomography (CT) scan of the thorax for the enrollee.