Persius/hicric huggingface dataset:
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 documentation does not support medical necessity for admission to an IRF. 
The enrollee has no acute medical complexity and no acute rehabilitation nursing needs for an IRF admission.  
 While the enrollee would benefit from physical therapy and occupational therapy, the enrollees rehabilitation 
needs can be safely met in an alternate and low intensity setting such as in 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93040 provided on August 10, 2022. 
 
You asked the Plan to pay for procedure code 93040. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 93040 is not supported in the medical record. Specifically, CPT code 93040 has a 
professional component (PC)/technical component (TC) indicator of 4 per the 2022 National Physician Fee 
Schedule. This means that code 93040 is a global test only code. This indicator identifies standalone codes for 
which there are associated codes that describe the professional component of the test only and the technical 
component of the test only. The total RVUs for global procedure only codes include values for physician work, 
practice expense, and malpractice expense. The total RVUs for global procedure only codes equal the sum of 
the total RVUs for the professional and technical components only codes combined. Based on this information, we decided that Medicare rules for coverage of procedure code 93040 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93040 provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve the manual lightweight wheelchair. You say that the 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 wheelchair can only be covered when a 
beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or 
walker. 
 
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 manual lightweight wheelchair. Our 
reviewer says that the manual wheelchair is not medically necessary. Our physician reviewer found the 
documents show that the patient is walking 320 feet with a rolling walker with contact guard to minimum 
assistance. Provided records do not clearly document that the patient's mobility deficit cannot be helped by the 
use of a walker. 
 
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 manual lightweight wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a manual lightweight wheelchair (K0003).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested raised toilet seat is not a covered benefit with your Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels (E0118). 
 
You asked the Plan to pre-approve a knee scooter/walker. You say that you need this scooter because you fell 
and shattered your ankle and sustained damage to your ribs and arms that makes using standard crutches 
painful. You also say your mobility will be affected by the lack of a knee scooter. The Plan denied your 
request. The Plan says Medicare says this item is not reasonable and necessary based on a lack of evidence. 
Medicare also says that a crutch substitute, such as a knee walker, has not been proven to be safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee scooter/walker have not been met. Specifically, Medicare says that a knee scooter/walker 
has not been proven to be safe and effective. Therefore, we decided that the Plan does not have to pre-approve 
a crutch substitute, lower leg platform, with or without wheels (E0118).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard liquid. 
 
You asked the Plan to pre-approve Gammagard liquid. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for 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 Gammagard liquid. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the review has determined that the 
requested use of liquid Gammagard is not FDA-approved for the enrollees diagnosis. Its use is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard liquid have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Gammagard liquid.
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 you are requesting reconsideration of the denied IRF 
authorization. The Plan denied your request. The Plan says that the admission to an IRF is not medically 
necessary. 
 
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 you do not require the intensity of services provided at an IRF. You are not 
shown to have an acute illness or injury. Your care needs can be met at a lower 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred 
drugs, Procrit or Retacrit. 
 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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed either of the preferred drugs. The reviewer found that there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and related supplies. 
 
You asked the Plan to pre-approve a continuous glucose monitor and related supplies. You say that the enrollee 
is blind and would benefit from having the requested CGM. You say that the enrollee is on insulin therapy and 
cannot monitor her blood sugar highs and lows. The Plan denied your request. The Plan says the request is not 
medically necessary because the records show that the enrollee does not have three or more daily 
administrations of insulin or a continuous subcutaneous insulin infusion pump. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor, and related supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor and related supplies.
Appeal type: Transportation
Decision: Unfavorable

 
 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 30, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. 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 $300 
copayment for ambulance services.  
 You have been asked to pay a $300 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on August 30, 2022.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
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 that the enrollee appears to be improving but does not have a stable feeding source 
and requires short-term additional acute care services that can safely be provided at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary for the enrollee to get better and have enough support while they are recovering. The Plan denied 
your request. The Plan says the medical records show the enrollee would not require a long-term stay in an 
LTACH facility and requested care can safely be received at another setting, such as a skilled nursing facility. 
 
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 he/she is currently receiving care. 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 health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trastuzumab Deruxtecan (Enhertu). 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this current request is not supported by the National Comprehensive Cancer Network 
(NCCN) guidelines. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the data for this 
request is still preliminary and in cell lines (in vitro). The listed use is not indicated, supported, or 
recommended in any of the compendia. This drug is not considered safe, effective, reasonable or necessary in 
this case. 
 
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 Trastuzumab Deruxtecan (Enhertu).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation - new or established 
patient (D0180) provided on September 28, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation - new or established patient. You say 
that the evaluation was requested by your family dentist. The Plan denied your request. The Plan says this 
service is 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 pay for a 
comprehensive periodontal evaluation - new or established patient (D0180) provided on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), although there are 
no pulmonary function tests to confirm and to assess severity. The enrollee was admitted with pneumonia and 
septicemia, and arterial blood gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure, 
but there is no ABG done while stable to confirm chronic carbon dioxide (CO2) retention. If this enrollee has severe COPD with chronic CO2 retention, they may benefit from bilevel positive airway pressure (BiPAP) 
with average volume-assured pressure support (AVAPS) and backup rate during sleep as an outpatient. 
Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Personal Care Attendant. 
 
You asked the Plan to pre-approve a Personal Care Attendant. You say that you received a prescription from 
your doctor. You say that you have arthritis and cannot do much work. You say that you need the extra hours 
for assistance. The Plan denied your request. The Plan says Medicare does not cover custodial care. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Personal Care Attendant have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a 
Personal Care Attendant.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 8, 2022, to June 
6, 2022. 
 
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 NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 8, 2022. The NOA was not received by the Plan until September 10, 
2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from May 8, 2022, to June 6, 2022.