Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 You asked the Plan to pre-approve Supartz FX. You say that you want to appeal this denial. The Plan denied 
your request. The Plan says the enrollee has not tried and failed one of the preferred drugs, Monovisc, 
Orthovisc, Synvisc or Synvisc One. 
 
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 Supartz FX. 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 the preferred drugs, Monovisc, Orthovisc, Synvisc or Synvisc 
One. The reviewer also found that there is no documentation provided indicating 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the enrollee needs 
transportation to dialysis treatments. The Plan denied your request. The Plan says the requested transportation 
exceeds the enrollee's benefit. 
 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 a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
24-trip limit.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the human cellular tissue product (HCT/P) provided on June 10, 2022. 
 
You asked the Plan to pay for the HCT/P procedure. You say that procedure code C1762 is a 361 product that 
meets all criteria outlined in 21 CFR 1271.10(a) are regulated as HCT/Ps are not required to be licensed or 
approved by the Food and Drug Administration (FDA). The Plan denied your request. The Plan says that this 
service is experimental and investigational. 
 
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 pay for the HCT/P procedure. Our reviewer says 
that the requested HCT/P procedure is considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation supports that the enrollee was suffering with left foot 
pain, and tenosynovitis of the extensor digitorum long. The documentation also advises that the enrollee has 
suffered with this pain for many months, and that the pain has been unresponsive to significant conservative 
care including strappings, injections, physical therapy, rest, ice, NSAIDs, and bracing. The reviewer found that 
human cellular tissue products are, as noted above, a mix of collagens, fibronectin, lamin, glucosaminoglycans, 
and water that can support the bodys natural ability to heal. Human cellular tissue product provides a structural 
foundation for weak and damaged tissue. Recent studies do show efficacy for these types of injections in 
healing tendon and soft tissue ailments. Therefore, the reviewer found that the requested treatment is medically 
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 the HCT/P procedure have been met. Therefore, we decided that the Plan has to 
pay for the human cellular tissue product (HCT/P) provided on June 10, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI. 
 
You asked the Plan to pre-approve an MRI. You say that the enrollee has completed 4 weeks of physical 
therapy with worsening symptoms and an MRI is required to determine further treatment. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for the requested MRI to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our reviewer says that the 
requested MRI does not meet the criteria for approval. Our physician reviewer found the records are inadequate 
to fully support that the MRI meets all Medicare criteria to be medically reasonable and necessary for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that you need this device to help with your 
breathing. The Plan denied your request. The Plan says that the doctor has prescribed a ventilator to help your 
breathing at various times of the day (night and day) because of your lung disease. Medicare does not cover 
ventilators used in this way. 
 
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 portable ventilator. Our reviewer says 
that the service is medically necessary. Our physician reviewer found you have a diagnosis of chronic 
respiratory failure consequent to chronic obstructive pulmonary disease and a paralyzed diaphragm. The health 
plan denied coverage for the ventilator stating the device would be used in a bilevel positive airway pressure 
(BiPAP) mode. Provided records document that the home ventilator is being requested for use in a mouthpiece 
ventilation-pressure control mode. The ventilator will not be providing BiPAP-level therapy as mouthpiece 
ventilation is not available on a BiPAP device. Criteria for coverage of the home mechanical ventilator (E0466) 
are 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 a portable ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve a portable ventilator (E0466).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from June 29, 2022, to July 20, 
2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing with records to prove medical 
necessity. The Plan denied your request. The Plan says this claim was not submitted with the appropriate 
artificial "admission" date for continuing care in 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that for home health services in 2021 that will 
continue in 2022, the home health agency shall submit a Notice of Admission with an artificial admission date 
corresponding to the From date of the first period of continuing care in 2022.  
 
We looked at the file and Medicare rules. The Notice of Admission submitted does not include an artificial 
admission date corresponding to the From date of the first period of continuing care in 2022. Based on this 
information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, 
we decided that the Plan does not have to pay for home health care provided from June 29, 2022, to July 20, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the leadless pacemaker with ablation (93650 and 33274) 
 
You asked the Plan to pre-approve the outpatient service. You say that the enrollee would get permanent 
adverse medical problems without this device. The Plan denied your request. The Plan says this device is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when 
furnished outside of a CMS approved coverage with evidence development (CED) study.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. Therefore, we decided that the Plan does not have to pre-
approve the leadless pacemaker with ablation (93650 and 33274)
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 enrollee is too weak to go home and 
unable to tolerate inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for an LTACH admission. 
 
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 is presently receiving appropriate services in the current acute care 
setting. Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a 
lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled 
nursing facility. The health plan has stated that continued care in the short-term acute hospital will be covered 
as is medically indicated. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on November 17, 2022 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that the services should be covered as the transport was the only way to transport the member 
safely and adequately. Medical records are submitted for proof. The Plan denied your request. The Plan says 
our policy covers non-emergency ambulance transportation when it is the only way to safely and adequately 
transport a member or if other means of transporting a member are unsafe due to a medical condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for ambulance service, basic life support, non-
emergency transport and ground mileage.  Our reviewer says that the ambulance transport services were not medically necessary. Our physician reviewer 
found the transportation via ambulance from the hospital upon discharge was not medically necessary. The 
enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport.  Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport and ground mileage provided on November 17, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour next test strips. 
 
You asked the Plan to pre-approve Contour next test strips. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says only the preferred brand products listed 
in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic testing supplies. Therefore, we decided that the Plan does not have to pre-approve Contour next test 
strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra-wide semi-electric hospital bed (code 
E0303). 
 
You asked the Plan to pre-approve a heavy duty extra-wide semi-electric hospital bed. You say that after you 
left the hospital, you were advised to get a bed that would accommodate positioning changes. The Plan denied 
your request. The Plan says you do not meet criteria for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that heavy duty extra-wide semi-electric hospital 
beds are only covered if your weight is more than 350 pounds but does not exceed 600 pounds. In this case, 
your medical records indicate that you weigh 257 pounds as of your last doctor visit. Your weight does not 
meet the requirements for coverage of the specific bed you have requested, so this item cannot be covered for 
you.  You can work with your doctor to request a different bed type. Therefore, we decided that the Plan does 
not have to pre-approve a heavy duty extra-wide semi-electric hospital bed (code E0303).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced prosthetic foot (L5981, L5986). 
 
You asked the Plan to pre-approve an advanced prosthetic foot. You say that an advanced prosthetic foot is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested item is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a lower limb prosthesis is covered when the 
beneficiary: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
 
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 an advanced prosthetic foot. Our 
reviewer says that the requested advanced prosthetic foot is medically reasonable and necessary in this case. 
Our physician reviewer found that not only does the medical record satisfy Medicare policy in demonstrating 
that the enrollee has a K3 functional level, but the Plan also attempts to create a more restrictive policy for 
defining K3 function than Medicare policy would allow. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an advanced prosthetic foot have been met. Therefore, we decided that the Plan 
has to pre-approve an advanced prosthetic foot (L5981, L5986).  
 
  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on February 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the 
inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes 
place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the inpatient POS code. The records show that the enrollee was under outpatient status when the services were provided. Therefore, we 
decided that the Plan does not have to pay for the outpatient services provided on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 43246 billed for date of service January 12, 2023. 
 
You asked the Plan to pay for code 43246. You say that all diagnoses on the claim are appropriate for the 
services billed. The Plan denied your request. The Plan says you billed this claim with an inappropriate pair of 
diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of Z93.1 and K94.23. Code K94.23 is an Excludes1 code 
under code Z93.1, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 43246 have not been met. Therefore, we decided that the Plan does not have to pay for code 
43246 billed for date of service January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second prosthesis. 
 
You asked the Plan to pre-approve a second prosthesis. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a prosthesis. The enrollees current prosthesis serves the same purpose as a 
second prosthesis. The requested second prosthesis is being requested for hygiene purposes as it is for 
bathing/showering. Therefore, we decided that the Plan does not have to pre-approve a second prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair lift. 
 
You asked the Plan to pre-approve a power wheelchair lift. You say that you use your power wheelchair to go 
everywhere and without the lift it is very hard to use. You said that your spouse cannot push you around so you 
are in need of this lift so that you can attend your doctor visits, tests, and treatments. The Plan denied your 
request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although 
this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, 
we decided that the Plan does not have to pre-approve a power wheelchair lift.