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 you need more intense rehab therapy every day so 
you do not lose range of motion in your knee. The Plan denied your request. The Plan says an IRF admission 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Praluent pen. 
 
You asked the Plan to pre-approve Praluent pen. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under 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 a Praluent pen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on April 5, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice on the date of 
service at issue in this appeal. The Plan says, per Medicare guidelines, the provider must bill Original Medicare 
for the services provided on April 5, 2020. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the critical care services provided on April 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that the requested drug is to be used in conjunction 
with intravenous chemotherapy CHOP (cyclophosphamide, hydroxydaunomycin, oncovin, prednisone) 
regimen. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under 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 Prednisone.  
 Benefits for Prednisone 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 continuous rental of oxygen equipment. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says rental oxygen is capped at 36 months. 
 
The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 
monthly rental payments. 
 
We looked at the file and Medicare rules. The file shows that the request is for rental oxygen equipment 
beyond the 36 month limit. 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 continuous rental 
of oxygen equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on March 21, 2022. 
 
You asked the Plan to pay for the durable medical equipment. 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. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided 
on March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home 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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the ventilator at issue meets Medicare criteria for medically necessary 
and reasonable for you. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used 
to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not reasonable and 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage 
 
You asked the Plan to pre-approve additional mileage. You say that you do not have anyone who can drive you 
to the provider's office. You also say that you have seen this provider in the past and you need to see him again 
due to a blood clot in your brain. The Plan denied your request. The Plan says you are requesting an additional 
11 miles for a total of 61 miles and your benefit only allows 50 miles. 
 
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 up to 24 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance. 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. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for 
patients that do not receive adequate relief from traditional conservative methods. You say that the Intracept 
procedure is medically necessary, and the denial is unwarranted. The Plan denied your request. The Plan says 
medical studies do not show that this procedure will work better than others. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this procedure is considered investigational and experimental due to lack of 
sufficient evidence to establish 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and accessories 
(E1002, E2300, E2310). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not covered for your condition. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair (K0856) and accessories (E1002, E2300, E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) 
and retainer crown - porcelain fused to high noble metal (D6750). 
 
You asked the Plan to pre-approve the dental services. You say that you are on a limited income. The Plan 
denied your request. The Plan says your benefit for the requested item or service will be exhausted with the 
pre-approval of these services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your $3,000 benefit has been exhausted with the pre-approval of the pontic and retainer crown for tooth 
#s 3-8. Therefore, we decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble 
metal (D6240) and retainer crown - porcelain fused to high noble metal (D6750).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (85060) provided on March 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
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 payment for CPT code 85060 is not supported in the medical record. Specifically, code 85060 is 
assigned a PC/TC indicator of 8. This means that no payment is recognized for code 85060 furnished to 
hospital outpatients or non-hospital patients. 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 
services (85060) provided on March 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve titration polysomnography (code 95811). 
 
You asked the Plan to pre-approve titration polysomnography. You say that titration polysomnography is 
medically necessary. The Plan denied your request. The Plan says titration polysomnography is not medically 
necessary based on Medicare guidelines and the Plan's Medical Policy. 
 
The Plan follows Medicare 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 pre-approve titration polysomnography. Our 
reviewer says that titration polysomnography is not medically necessary.  
 
 Our physician reviewer found that based on the medical records provided there is no documentation that the 
facility-based titration polysomnography test at issue in this case meets Medicare and Local Coverage 
Determination (LCD): Polysomnography and Sleep Testing - L33405 criteria for medically reasonable and 
necessary. The provided records do not document that a home sleep study is contraindicated 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 titration polysomnography have not been met. Therefore, we decided that the 
Plan does not have to pre-approve titration polysomnography (code 95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral device to reduce upper airway collapsibility 
(E0486). 
 
You asked the Plan to pre-approve an oral device to reduce upper airway collapsibility. You say that the 
requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage 
for the requested item have not been met.  
The Plan must follow Medicare rules. The rules say that an oral appliance coded E0486 is covered when the 
criteria detailed in the Medicare rules section have been met.  
 
We looked at the file and Medicare rules. In this case, the medical records do not document that the item at 
issue will be provided and billed for by a licensed dentist. Based on this information, we decided that Medicare 
rules for coverage of an oral device to reduce upper airway collapsibility have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an oral device to reduce upper airway collapsibility 
(E0486).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to approve these services. You say that your health has improved with the CGM. The Plan 
denied your request. The Plan says the criteria for coverage are not met. 
 
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 you do not treat with insulin three 
or more times per day or use an insulin pump. 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 approve a 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that medically necessary care is available in network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve psychotherapy services to be provided by the requested out-of-network 
provider. You say that your wife is a Japanese national with permanent green card and she speaks broken 
English and she needs a Japanese speaking counselor for her treatment. You say that your wife has been seeing 
this provider for many years and was benefitting by seeing this provider. The Plan denied your request. The 
Plan says the enrollee must receive care from a network provider except for emergency or urgently needed 
services that you get from an out-of-network provider. If you need medical care that Medicare requires our 
Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-
network provider. A prior authorization is required if you are seeking non-emergency out-of-network care. 
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside 
the Plans service area. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services to be 
provided by the requested out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that this is necessary. The 
Plan denied your request. The Plan says that this request exceeds the benefit limit. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for code 92928. 
 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, we have confirmed that code 93010 
is a column II code to column I code 92928. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 93010 billed for date of service March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home 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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the home ventilator at issue in this case meets Medicare criteria for 
medically reasonable and necessary. As stated in the Local Coverage Determination (L33800): "Claims for 
ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not reasonable and 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.