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

 
We decided that the Plan does not have to pre-approve a Life2000 system. 
 
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 the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and coronary artery disease. He already has a home ventilator. The Life2000 
system is not a true ventilator because it is not capable of providing full ventilatory support.  It is intended to be 
used during activity, and there is inadequate evidence that it is beneficial in the treatment of any chronic lung 
disease. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Life2000 system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS system. 
 
You asked the Plan to pre-approve CardioMEMS system. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says this is considered as experimental, 
investigational or unproven services. 
 
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 CardioMEMS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardioMEMS system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services to return to being 
independent. The Plan denied your request. The Plan says you do not meet the requirements for an IRF 
admission.  
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation program provided in an 
IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that the requested drug is medically necessary to treat 
the enrollee's anemia. The Plan denied your request. The Plan says the drug requested does not meet the step-
therapy requirements for approval. 
 
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 Feraheme. Our reviewer says that the 
requested drug does not meet the criteria necessary for approval. Our physician reviewer found the Plan 
requires a trial of Ferrlecit, Infed or Venofer before they will approve the requested drug. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would 
have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are 
not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires interdisciplinary therapy care 
and requires close daily oversight by a rehabilitation physician in an inpatient setting. 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 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. The patient was 
admitted for respiratory failure and congestive heart failure. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 23, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on March 23, 2023, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 28, 
2023, to August 01, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $380 
copayment for inpatient hospital care. 
 
You have been asked to pay a $380 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care 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. The total amount you owe is $1,520 ($380 x 4 days = $1,520). Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital care provided on July 28, 2023, to August 
01, 2023.
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 the medical records provided support the 
need for the requested LTACH admission.  The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH.  
 
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 this case pertains to a 68 year old who was admitted to the hospital for critical limb 
ischemia. The hospital course has been quite complicated and currently has a tracheostomy and gastrostomy 
tube. The enrollee is also on a precedex drip and is not appropriate for transfer at this time. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided from 
March 3, 2023, to March 27, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says the pneumatic compression device (E0675) does not 
meet the requirements for approval. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided from March 3, 2023, to March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6740) teeth #6 and #7 provided August 3, 
2023. 
 
You asked the Plan to pay for the dental services. You say that tooth #6 is fractured at the gumline and unable 
to be fixed. The Plan denied your request. The Plan says for dental conditions that have two or more possible 
treatments, the Plan will cover the lowest cost treatment, as long as it is proven to provide satisfactory results. 
If you choose to receive a higher cost treatment, you will be responsible to pay for the difference. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the dental services. Our physician reviewer 
found the documentation provided indicates that tooth #6 fractured and could not be restored. A fixed bridge is 
requested to replacing tooth #6. A fixed bridge may be covered to replace a missing anterior maxillary tooth 
(#6) if there are no missing posterior teeth in the arch. There were no radiographs provided showing the entire 
maxillary arch; therefore, a determination that the criteria for coverage for a fixed bridge could not be 
determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pay for a retainer crown (D6740) teeth #6 and #7 provided August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on August 4, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided on August 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the compression stockings (A6549) and 
the support garments (A4467) that were issued from August 4, 2022, to December 6, 2022. 
 
You asked the Plan to provide reimbursement for the compression stockings. You say that these items are 
covered for cancer patients. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing. The rules also says that 
code A4467 does not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. 
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to provide reimbursement for 
the compression stockings (A6549) and the support garments (A4467) that were issued from August 4, 2022, to 
December 6, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Remicade. 
 
You asked the Plan to pre-approve the medication. You say that you have been using Inflectra, but it is no 
longer available, and the Plan approved Renflexis may not be safe with your prior history of cancer. The Plan 
denied your request. The Plan says the criteria for Remicade has not been met and it is unclear why Inflectra is 
not available with your provider. 
 
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. Medicare rules also say that for Medicare to consider coverage and payment for any item 
or service, the information submitted by the supplier or provider must corroborate the documentation in the 
beneficiarys medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Remicade have been met. No medical 
records showing whether you have tried and failed the Plans preferred drug, Inflectra, have been submitted 
despite multiple requests from the Plan. Therefore, we decided that the Plan does not have to pre-approve the 
use of Remicade.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 30, 2023, to 
February 8, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of A41.9 (sepsis, unspecified 
organism), N17.0 (acute kidney failure with tubular necrosis), J96.21 (acute and chronic respiratory failure 
with hypoxia). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 defined as sepsis, unspecified organism, 
N17.0 defined as acute kidney failure with tubular necrosis, J96.21 defined as acute and chronic respiratory 
failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our physician reviewer found that the sepsis 3 criteria was not met as 
there was insufficient support for organ failure directly related to an unregulated response to infection. Also, 
reports show the patient was not in respiratory distress, didn't require more than low dose oxygen support 
(baseline) to support respiratory failure. Therefore, the following codes A41.9 (sepsis, unspecified 
organism), J96.21 (acute and chronic respiratory failure with hypoxia), and N17.0 (acute kidney failure with 
tubular necrosis).   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 30, 2023, to February 8, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 8, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
provided by an out-of-network provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided on September 8, 2023, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided on August 31, 
2023. 
 
You asked the Plan to waive the coinsurance for the injections. You say that your only copayment was $25. 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the injections. This item/service falls within the Medicare 
Part B prescription drugs 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. The total you owe is $782.03 ($3,910.17 allowed amount x 20% = $782.03). Therefore, 
we decided that the Plan does not have to waive the coinsurance for the injections provided on August 31, 
2023.