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

 
We decided that the Plan does not have to pre-approve hydroxyzine oral tablets. 
 
You asked the Plan to pre-approve hydroxyzine oral tablets. You say that the enrollee has been on hydroxyzine 
since January 21, 2022, with good outcome and relief of symptoms. The Plan denied your request. The Plan 
says coverage of the requested hydroxyzine oral tablets is not a covered Medicare Part B 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 hydroxyzine oral tablets.  
 
Benefits for hydroxyzine oral tablets 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 pre-approve percutaneous implantation of neurostimulator electrode 
array. 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous implantation of neurostimulator 
electrode array is only covered for certain indications. 
 
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 percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the documentation does not support that the requested 
services are medically reasonable or necessary. Our physician reviewer found you have a history of chronic 
back pain due to lumbar disc degeneration and lumbar radiculopathy. The record sent by his provider indicates 
that he has chronic back pain that is helped by walking. It is noted that he had previous injections though 
details were not made available. It is also noted that you had a previous unsuccessful spinal cord stimulator trial 
with a different provider, but no further details were provided. There is no notation of details of prior physical 
therapy and he has not had a psychological evaluation. Therefore, you do not meet criteria for the requested 
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 percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of 
neurostimulator electrode array.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET imaging (78816) provided on November 15, 2022. 
 
You asked the Plan to pay for PET imaging. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scan services must be billed with the 
appropriate diagnosis codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET imaging have not been met. Therefore, we decided that the Plan does not have to pay for PET 
imaging (78816) provided on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve SI joint RFA. 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 SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SI joint ablation is experimental for back pain. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair, walker, commode, and accessories billed for 
date of service October 4, 2022. 
 
You asked the Plan to pay for the medical equipment. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says you did not provide documentation to support 
payment for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery. The reason why the proof of delivery is not valid is 
because the delivery ticket explicitly states that these items were picked up on October 3, 2022.  However, you 
billed with date of service October 4, 2022.  This is why the documentation does not match your claim. 
Therefore, we decided that the Plan does not have to pay for the wheelchair, walker, commode, and accessories 
billed for date of service October 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are doing a home exercise program, 
but there are stretches and manipulations you cannot do at home. The Plan denied your request. The Plan says 
this is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested physical therapy is generally accepted as a specific and 
effective therapy for your condition. You have had 11 sessions of physical therapy and are currently 
performing a home exercise program and dynamic stretching and strengthening exercises. While you may have 
some pain with more strenuous activity such as walking fast, you are independent with mobility and 
performing daily activities. You can manage pain with a home exercise program. The services of a skilled 
therapist are not needed. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. You say you live in a rural area where finding skilled care is very difficult, 
and the enrollee needs the LTACH before you can handle the home care. The Plan denied your request. The 
Plan says the LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 3, 2022, to May 
26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
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 May 3, 2022, to May 26, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on November 8, 
2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the physician order submitted is in valid. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain a valid physician order for the supplies provided in this case. Review of the file 
shows that the prescription within the documents submitted indicate the prescribing credentials are Certified 
Registered Nursing Anesthetist, which does not meet the definition of a treating physician. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the electrical stimulator supplies provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the treatment has fewer side effects. 
The Plan denied your request. The Plan says this is not the standard of care for prostate cancer. 
 
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 requested services. Our physician 
reviewer found that to date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than intensity modulated or image guided radiation therapy. The generally accepted standard of care 
for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to 
patients. While NCCN guideline consider proton therapy a reasonable alternative, they do not describe it as 
being necessary in lieu of non-proton-based treatment and are quite explicit in that there is no evidence of its 
superiority. Therefore, the request is not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service June 17, 
2022. 
 
You asked the Plan to pay for procedure code 99214. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed is not supported. 
 
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, the CPT Code Manual definition of code 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making or must reach 30-39 minutes of total time (non-face to face and 
face to face total time) spent on the date of the encounter. 
 
 
 We asked our coder 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 procedure code 99214. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee returned for a follow-up visit 
after having been seen for complaints of pain of the left knee. The documentation does not support moderate 
level of medical decision making or total time required of the code billed. Therefore, code 99214 is not 
supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99214 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99214 billed for date of service June 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rhythm turn lateral rotation mattress. 
 
You asked the Plan to pre-approve a rhythm turn lateral rotation mattress. You say that a rotator mattress will 
help to prevent bed sores. You say that the enrollee's back presents red and tender areas on the skin. You also say it is painful for them. The Plan denied your request. The Plan says the requested mattress is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that that a Group 2 support surface may be covered if the 
beneficiary meets certain criteria. 
 
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 rhythm turn lateral rotation mattress. 
Our reviewer says that the requested mattress is not medically necessary. Our physician reviewer found the 
provided documentation indicates that the enrollee has reduced bed mobility due to weakness from multiple 
sclerosis. The reviewer found that the enrollee's caregiver is currently re-positioning the enrollee while in bed 
to prevent skin breakdown. The reviewer found that the enrollee's physical examination findings do not 
demonstrate the presence of pressure wound and there is not a Stage 2 or higher pressure wound. There is no 
documentation indicating that a Group 1 support surface has been utilized or attempted for pressure relief. 
Therefore, the reviewer found that the requested Rhythm Turn Lateral Rotation Mattress is not 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 a rhythm turn lateral rotation mattress have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a rhythm turn lateral rotation mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on October 
14, 2022. 
 
You asked the Plan to pay for the neuromuscular stimulator. The Plan denied your request. The Plan says this is 
not covered for the billed diagnosis. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the item provided in this case. The packing slip indicates that electrodes and batteries were send on October 14, 2022, and delivered on October 18, 2022. The 
packing slip does not show that a neuromuscular stimulator was included in this shipment. Therefore, we 
decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on October 14, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport provided on September 30, 2022. 
 
 
You asked the Plan to pay for air ambulance transport. You say that the medical records provided support the 
need for the air ambulance transport. The Plan denied your request. The Plan says the air 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 air ambulance transport. Our reviewer says 
that the air ambulance transport service was not medically necessary Our physician reviewer found the enrollee 
was involved in a motor vehicle collision and had signs of a head injury, but stable vital signs. It appears that 
the enrollee could have been safely transported by ground to a local hospital for initial evaluation. Even if air 
transport was warranted, it does not appear that the enrollee was taken to the closest available 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 air ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for the air ambulance transport provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that a continuous positive airway pressure (CPAP) 
device is no longer meeting the enrollee's needs. The Plan denied your request. The Plan says a ventilator is not 
covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health telehealth services you received from 
November 10, 2022, to November 22, 2022. 
 
You asked the Plan to pay for the telehealth services. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
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 there is no coverage 
for out-of-network telehealth services. 
 
Review of the file shows that you were provided out-of-network mental health telehealth services from 
November 10, 2022, to November 22, 2022. These services are not covered by the Plan. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the mental health telehealth services you received from November 10, 2022, to 
November 22, 2022.
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 IRF services would help the enrollee to heal faster. 
The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not 
meet the requirements for approval. 
 
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 based on the medical records provided the complexity of the enrollees nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services, 
but the medical records provided do not clarify why the enrollee requires an intensive IRF therapy program. 
There is no support in the documentation that the enrollee requires the intensive medical care and 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.