Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 7 additional home health physical therapy (PT) visits (G0151 x7). 
 
You asked the Plan to pre-approve the additional PT visits. You say that the enrollee will benefit from 
continuing skilled home health PT. The Plan denied your request. The Plan says that the medical record does 
not document a clearly evident need for the services of a skilled physical therapist. The Plan also says that the 
enrollee has already been educated on a home exercise program, and there is no documentation of an active or 
acute on chronic condition that would necessitate a new program. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional PT visits. Our reviewer 
says that the 7 additional PT visits are reasonable and necessary. Our physician reviewer found the clinical 
documentation has clear functional goals (short term and long term) that have not been met, including bed 
mobility and transfers. Our reviewer found that additionally, home bound status is documented, thus 7 
additional home health PT visits are 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 additional PT visits have been met. Therefore, we decided that the Plan has 
to pre-approve 7 additional home health physical therapy (PT) visits (G0151 x7).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozurdex. 
 
You asked the Plan to pre-approve Ozurdex. You say that the requested drug is medically necessary for the 
enrollee's treatment of primary open-angle glaucoma. The Plan denied your request. The Plan says the drug's 
requested use is off-label and not medically accepted. The Plan says that no support was found for the 
requested use of this drug in this clinical scenario. 
 
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 Ozurdex. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found treatment with Ozurdex intraocular 
implants is not Food and Drug Administration-approved for the treatment of primary open-angle glaucoma, 
cystoid macular degeneration, nonexudative age-related macular degeneration and vitreous degeneration. 
Treatment with Ozurdex intraocular implants for primary open-angle glaucoma, cystoid macular degeneration, 
nonexudative age-related macular degeneration and vitreous degeneration is not supported by one of the major 
drug compendia or by clinical research that appears in a Medicare-approved medical journal. The requested 
drug is not considered reasonable and 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 Ozurdex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ozurdex.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found while you have a history of atrial 
fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in your 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 placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug system provided from October 11, 2021, 
through October 17, 2021, billed with A4305. 
 
You asked the Plan to pay for the services described by A4305. You say that these claims should be paid. The 
Plan denied your request. The Plan says A4305 is noncovered. Codes A4220 and A4221 are being handled as a 
clerical reopen request separately. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the Medicare definition of durable medical equipment. Therefore, we decided that the Plan does not have to pay for 
the disposable drug system provided from October 11, 2021, through October 17, 2021, billed with A4305.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on March 17, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) provided 
on January 27, 2022. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says this is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. Per L33829, the requested PCD (E0675) is not medically reasonable 
and necessary. Based on this information, we decided that Medicare rules for coverage of the PCD have not 
been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device 
(PCD) (E0675) provided on January 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64635 billed for date of service January 11, 
2022. 
 
You asked the Plan to pay for procedure code 64635. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64635 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64635 have not been met. 
 
We have also confirmed that code procedure code 64636 is an add-on code and has not been billed with an 
appropriate primary procedure code. As the primary procedure code (64635) is not payable, the add-on code is 
also not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 64635 billed for date of service January 11, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0854, E2617, 
E2609, E2386x2, K0040x2, E2363x, E0973x2, E1028). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the wheelchair is 
medically necessary. The Plan denied your request. The Plan says you do not have a qualifying diagnosis 
causing mobility limitation for which group 3 power wheelchair is medically needed. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found a group 3 power 
wheelchair can be covered if the medical necessity for a PWC is met and if the disorder causing the mobility 
limitation is a neurological condition, myopathy or congenital skeletal deformity. You must also require a drive 
control interface, power tilt or a power recline seating system and if there has been a specialty evaluation that 
was performed by a licensed/certified medical professional, such as a physical or occupational therapist. An 
expandable controller is an electronic system that is capable of accommodating one or more additional features 
and can operate 3 or more powered seating options. In this case, you have multiple medical problems with 
resulting functional deficits. Criteria for a group 3 power wheelchair is not met. The documentation does not 
indicate that you have any pressure injuries or requires intermittent catheterization of the bladder that would 
necessitate power tilt or recline. Additionally, you do not have a neurological problem causing her mobility 
deficits. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0854, E2617, E2609, 
E2386x2, K0040x2, E2363x, E0973x2, E1028).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge day management coded 99217 
provided on May 17, 2022. 
 
You asked the Plan to pay for the observation care discharge day management. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate]). 
 
 We find that CPT code 99217 is not supported in the medical record. Specifically, no qualifying initial or 
subsequent observation care service was billed in the enrollee's claims history. This means this discharge 
service is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
observation care discharge day management have not been met. Therefore, we decided that the Plan does not 
have to pay for the observation care discharge day management coded 99217 provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 16, 2021, billed 
with codes 81210, 81206, and 81235. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly and is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 16, 2021, billed with codes 81210, 81206, and 81235.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan/ 
 
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 Gemtesa.  
 
Benefits for Gemtesa 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says a Medicare Advantage Plan can require a trial of a preferred drug to treat a medical 
condition before covering another non-preferred drug. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of a trial of Ferrlecit, Infed, Venofer before they will approve the requested drug. In this case, the patient 
has not tried and failed the required drugs. There is no documentation provided indicating that the plans 
required drugs would likely be less effective and/or likely have adverse effects 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the InSpan device. 
 
You asked the Plan to pre-approve the InSpan device. You say that the requested InSpan device is medically 
necessary. The Plan denied your request. The Plan says the requested InSpan device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the InSpan device. Our reviewer says 
that the requested InSpan device is not medically necessary. Our physician reviewer found the InSpan device is 
experimental. More research is needed to show safety and efficacy. 
 
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 InSpan device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the InSpan device.
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 the enrollee was in an accident and since has been 
released. You say that the enrollee was stabilized post-operatively and discharged to a SNF for therapy and 
continuation of care. You say that the enrollee is ready for IRF care. The Plan denied your request. The Plan 
says the enrollee's medical records does not show a need to take part in three hours of therapy a day at least five 
days per week. The service the enrollee need can be provided safely in other settings such as a SNF, home 
health, 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical records support a need for physical and occupational therapy, there is no documented need for 
intensive rehabilitation services. 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 IRF admission and services.
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 the enrollee's clinical condition meets full inpatient 
acute rehabilitation criteria. You say that the lower level of care in skilled nursing cannot provide the total 
interdisciplinary team approach and higher intensity therapy needed. The Plan denied your request. The Plan 
says the enrollee does not meet the 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on March 22, 2022. 
 
You asked the Plan to pay for the ambulance transportation. You say that this was medically necessary 
transportation and should be reimbursed. The Plan denied your request. The Plan says this was not billed in 
accordance with LCA rules. 
 
The Plan must follow Medicare rules. Medicare rules say that the local contractor indicates that ambulance 
claims must report a secondary diagnosis code of a list of four to be covered.  
 
We looked at the file and Medicare rules. The claim at issue reports only one diagnosis code. There is no 
secondary code reported from the list in the rules. Based on this information, we decided that Medicare rules 
for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not 
have to pay for the ambulance transportation provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide routine transportation via air and meals during transportation 
to see an out-of-network surgeon. 
 
You asked the Plan to provide routine air transportation and meals. You say that you want to see this out-of-
network surgeon and need air transportation in order to do so. The Plan denied your request. The Plan says 
your supplemental transportation benefit only covers ground transportation and meals are only covered in an 
inpatient or skilled nursing facility setting. Therefore, the requested services are denied as non-covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers routine transportation by ground transport only. The Plan does not cover meals outside of 
inpatient or skilled nursing facility care.  
 
We looked at your request, the records in the case file, and the rules. 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 provide routine transportation via air and meals during transportation to see an out-of-
network surgeon.