Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have  to pay for the self-administered drug (A9270) and waive the 
coinsurance for the intravenous infusions (96365, 96366) and IVIG privigen (J1459). 
 
You asked the Plan  to pay for the self-administered drug and waive the coinsurance for the intravenous 
infusions and IVIG privigen. You say that the cost share is wrong. 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 10% 
coinsurance for Medicare Part B prescription drugs. Self-administered drugs are not covered. 
 
You have been asked to pay a 10% coinsurance for to pay for the self-administered drug and waive the 
coinsurance for the intravenous infusions and IVIG privigen. 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. Therefore, we decided that the Plan does not have  to pay for the self-administered drug (A9270) 
and waive the coinsurance for the intravenous infusions (96365, 96366) and IVIG privigen (J1459).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service August 3, 2023. 
 
You asked the Plan to pay for the lab testing. You say that you were not told the service was not covered. The 
Plan denied your request. The Plan says that the lab test is not covered by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The lab testing was provided by a contract provider. The file does not show that the Plan provided notice that 
the lab testing would not be covered. Under Medicare rules, this means the lab testing is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the lab testing billed for date of service August 
3, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. The Plan denied your request. The Plan says as 
this enrollee is not on insulin and does not have documentation of problematic hypoglycemia, a CGM is not 
covered under current Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vest Airway Clearance System. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 system. Our reviewer says that the 
requested system is not medically reasonable or necessary. Our physician reviewer found that the enrollee does 
not have supportive evidence of failure of standard therapy for secretion mobilization.  There is no supportive 
data for high frequency chest wall oscillation devices. The enrollee does not have any disease which requires 
high frequency chest wall oscillation device. There is no documented use of a mechanical in-exsufflation 
device. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vest Airway Clearance System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coude tip intermittent urinary catheter and lubricant to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a Coude tip intermittent urinary catheter and lubricant to be provided by an 
OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are 
in-network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 Plan has network providers available who are capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 a Coude tip intermittent urinary catheter and 
lubricant to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen. 
 
You asked the Plan to pre-approve the medication. You say that the request was submitted with the wrong 
diagnosis code. The correct code is for common variable immunodeficiency. The Plan denied your request. The 
Plan says the requested treatment order of Privigen 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 the medication. Our reviewer says that 
the request is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
myelodysplasia and infections. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition.  The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation.  
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Privigen.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchial thermoplasty (31660, 31661). 
 
You asked the Plan to pre-approve bronchial thermoplasty. You say that you are asking that this indicated, non-
experimental/non-investigational procedure be approved for the enrollee to improve their asthma control. The 
Plan denied your request. The Plan says the procedure is found to have an uncertain role at this time. 
 
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 bronchial thermoplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not meet the standard requirements for bronchial thermoplasty at 
this time. The enrollee does not have the severity of disease in which this procedure was initially investigated 
on nor treated. Hence, there is no indication for bronchial thermoplasty per the documentation provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bronchial thermoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bronchial thermoplasty (31660, 31661).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on August 21, 2023. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the wound care services provided on August 21, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, 97112, and 97530 rendered from 
August 1, 2023, to August 10, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
The CPT code manual definition of the denied codes is: 
 
CPT 97110:  
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and 
endurance, range of motion and flexibility 
 
CPT 97112: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 
 
CPT 97530: 
 
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional 
performance), each 15 minutes 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the codes in question are not 
supported. The record states that the services were performed in a home setting by a physical therapy assistant. 
There are more specific codes for these services. 
 
We looked at this coder's review, the file, and Medicare rules. 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 procedure codes 97110, 97112, and 97530 rendered from August 1, 2023, to August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient would greatly benefit from this 
equipment. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
average volume-assured pressure support (AVAPS) mode with auto-expiratory positive airway pressure that 
could be delivered by BiPAP is not covered.  
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has severe COPD 
with an forced expiratory volume in the first second (FEV1) of 34% of predicted. A recent arterial blood gas 
was consistent with chronic carbon dioxide retention. Our reviewer found that there is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. This patient may benefit from BiPAP with volume assurance and 
automatic expiratory pressure adjustment as an outpatient. Our physician reviewer found that the medical 
records do not show this has been tried. Medicare does not cover a home ventilator when used at settings that 
can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 13, 2023, to 
February 8, 2023. 
 You asked the Plan to pay for the home health services. You say that there is a NOA on file. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 13, 2023. The NOA was not received by the Plan until May 17, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 13, 2023, to February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implanted neurostimulator for incontinence. 
 You asked the Plan to pre-approve implanted neurostimulator for incontinence. You say that the enrollee has 2 
types of incontinence, stress and urgent. He stated that the procedure is to treat the urgency aspect, not the 
stress. The Plan denied your request. The Plan says this does not meet the criteria for coverage. 
 
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 implanted neurostimulator for 
incontinence. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
records do not document that the patient has been refractory to all conventional therapy as required. In addition, 
records document the presence of stress incontinence for which the neurostimulator is excluded from coverage 
in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implanted neurostimulator for incontinence have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implanted neurostimulator for incontinence.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Romosozumab injection provided on 
August 21, 2023. 
 
You asked the Plan to waive the coinsurance for the Romosozumab injection. You say that the cost share is 
wrong. 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 Romosozumab injection. 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. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the Romosozumab injection provided on August 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 3, 2023, to August 
1, 2023. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 5, 2023. The NOA was not received by the Plan until October 10, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from July 3, 2023, to August 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies allowance provided on September 20, 
2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment. 
The Plan denied your request. The Plan says based on the guidelines, the denial is appropriate. The Plan must follow Medicare rules. Medicare rules say that in order to bill code A4238 or A4239, the 
supplier must have previously delivered quantities of supplies that are sufficient to last for one (1) full month, 
thirty (30) days, following the DOS on the claim. Billing more than three (3) UOS per ninety (90) days of code 
A4238 or A4239 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the diabetic supplies allowance provided on September 20, 2023.
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 are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While documentation 
supports the need for skilled therapy, it does not support the medical necessity of an 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 pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
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 ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there was no documentation of at least 50% sustained improvement in pain relief and/or 
improvement in function measured from the enrollee's baseline for at least three months from the previous ESI. 
There is no documentation provided indicating that the requested ESI will be performed using a different 
approach, level and/or medication if appropriate. Therefore, the criteria for coverage 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 the ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ESI.