Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you need this bed because you 
have difficulty breathing when sleeping. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
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 appealing the denial for LTACH. 
The Plan denied your request. The Plan says that LTACH is not 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 has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that are not currently being provided but that would 
be available at the LTACH facility. The elements of the coverage rules are not satisfied.  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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injections. 
 You asked the Plan to pre-approve the Orthovisc injections. You say that the enrollee has had a trial of 
Euflexxa which did not have a positive effect. The enrollee has had success with Orthovisc in the past, and this 
should be allowed rather than a trial of a different agent.  The Plan denied your request. The Plan says the rules 
require a failure of both preferred agents before Orthovisc can be approved.  
 
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 Orthovisc injections. Our reviewer 
says that the request for Orthovisc is not medically necessary based on step therapy rules.  Our physician 
reviewer found the Plan requires a trial of both Euflexxa and Synvisc-One before they will approve the 
requested drug. In this case, the enrollee has not tried and failed Synvisc. There is no documentation provided 
indicating that the Plans required drug 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 Orthovisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Orthovisc injections.
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 rehab before returning home because 
you live alone and are at risk for falling. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and your needs can be met in other settings.  
 
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. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the request is not medically necessary because your 
records show you do have not had a colonoscopy within the last 12 months to look for the etiology of the 
anemia. In addition, there is no documentation from your provider to suggest that the cause of the anemia is 
suspected to be from occult gastrointestinal bleeding.  
 
The Plan must follow Medicare rules. Medicare rules say that a wireless capsule endoscopy may be covered for 
enrollees who have had upper and lower GI endoscopies within the past 12 months EGD and colonoscopy) that 
have failed to identify a bleeding source. 
 
We looked at the file and Medicare rules. In this case the records do not show that the enrollee has not had a 
colonoscopy in the last 12 months. Based on this information, we decided that Medicare rules for coverage of a 
wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-
approve a wireless capsule endoscopy (91110).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia. 
 
You asked the Plan to pre-approve Cimzia. You say that the requested Cimzia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Avsola, Inflectra, and Renflexis first, OR have 
used Cimzia in the last 365 days.  
 
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 Cimzia. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the Plan's 
required drug(s) 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 Cimzia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cimzia.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria. 
 
You asked the Plan to pre-approve Simponi Aria. You say that the requested Simponi Aria is medically 
necessary. The Plan denied your request. The Plan says the enrollee must try and fail Inflectra or Renflexis 
first. 
 
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 Simponi Aria. Our reviewer says that 
the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of 
Inflectra or Renflexis first before they will approve the requested drug.  In this case, the enrollee has not tried 
and failed a required drug. 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 Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the implantation of a carotid sinus Baroreflex activation device. 
 
You asked the Plan to pre-approve the implantation of a Baroreflex activation device. You say that the 
requested procedure is medically necessary. The Plan denied your request. The Plan says that this procedure 
does not meet the definition of medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the implantation of a Baroreflex 
activation device. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found that the Food and Drug Administration has approved the 
Barostim Neo System for the improvement of symptoms in enrollees with advanced heart failure who are not 
suited for treatment with other heart failure devices. The system has been shown to be safe, and significantly 
improved quality of life, exercise capacity, and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels.  
 
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 Baroreflex activation device have been met. Therefore, we decided that the 
Plan has to pre-approve the implantation of a carotid sinus Baroreflex activation device.  
 
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 Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested Botox to treat Myofascial Pain due to 
Pelvic Floor Dysfunction is medically necessary.  The Plan denied your request. The Plan says the requested 
Botox to treat Myofascial Pain due to Pelvic Floor Dysfunction is not medically necessary.  
 
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 Botox. Our reviewer says that the 
requested Botox to treat Myofascial Pain due to Pelvic Floor Dysfunction is not medically necessary.  Our 
physician reviewer found the requested use of Botox is not Food and Drug Administration-approved for the 
treatment of myofascial pain due to pelvic floor dysfunction. The use of Botox for the treatment of myofascial 
pain due to pelvic floor dysfunction is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use of Botox for the treatment of myofascial 
pain due to pelvic floor dysfunction is not indicated, supported, or recommended in any of the compendia. The 
use of Botox for the treatment of myofascial pain due to pelvic floor dysfunction does not meet Medicare 
criteria as safe and effective and otherwise reasonable and necessary for this 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99239) provided on September 16, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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. 
 
In this case, the CPT Code Manual definition of code 99239 is Hospital discharge day management. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, no discharge note was 
included in the provided records. Based on this information, we decided that Medicare rules for coverage of the 
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
services (99239) provided on September 16, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on January 4, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the facility must be enrolled to participate in the 
Medicare program.  
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and clinic services provided on December 29, 
2022, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the office visit. You say that the facility is a walk-in clinic. You say that if 
enrollee's use non-contracted opioid treatment programs (OTPs), plans must contact them to coordinate 
benefits and timely payments. You also say that the original claim was timely. The Plan denied your request. 
The Plan says the services were not urgent or emergent. The Plan also says that prior authorization was not 
obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit and clinic services provided on December 29, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology procedures of the lower extremities 
(code 73630 26 RT) provided on January 3, 2023. 
 
You asked the Plan to pay for diagnostic radiology procedures of the lower extremities (code 73630 26 RT). 
You say that the claim denied as duplicate in error. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on February 22, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for diagnostic radiology procedures of the lower extremities 
(code 73630 26 RT) have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic 
radiology procedures of the lower extremities (code 73630 26 RT) provided on January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on November 
8, 2022. 
 
You asked the Plan to pay for the Cxbladder monitor test. You say that that this service was medically 
necessary. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on November 8, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on June 18, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
timely filling requirement for primary or secondary claims is one calendar year (12 months) from the date of 
service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until October 17, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on  
June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limb compression wraps (E0673, E0656) provided on 
September 22, 2022. 
 
You asked the Plan to pay for the limb compression wraps. You say that these items were medically necessary. 
The Plan denied your request. The Plan says the service billed is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that any other accessories, options, and supplies used 
with a pneumatic compression device E0676 are included in the payment for HCPCS code E0676 at the time of 
initial issue and must not be billed separately to Medicare.  
 
We looked at the file and Medicare rules. The limb compression wraps billed are included in code E0676 and 
cannot be separately reported. Based on this information, we decided that Medicare rules for coverage of the 
limb compression wraps have not been met. Therefore, we decided that the Plan does not have to pay for limb 
compression wraps (E0673, E0656) provided on September 22, 2022.
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 have serious impairment bodily functions that 
include coughing mobile issues and a broken clavicle. 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. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve implantation of a CardioMEMS device. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 implantation of a CardioMEMS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient 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 implantation of a CardioMEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289, C2624).