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

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). You asked the Plan to pre-approve the requested services. You say that the enrollee's long-term risk of cardiac 
toxicity is higher with IMRT. The Plan denied your request. The Plan says there is no research this treatment 
responds better to the enrollee's type of cancer. 
 
The Plan follows Medicare rules. Medicare rules say that proton beam therapy is only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found that while planning records are provided, the case file does not demonstrate that standard three 
dimensional or IMRT planning exceed accepted dose constraints or provide a plausible reason for why that 
might be the case. For esophageal cancer, treated to approximately 45-50.4 gray (Gy), proton therapy is not 
likely to be 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mechanical traction therapy to be provided by a 
chiropractor. 
 
You asked the Plan to pre-approve mechanical traction therapy. The Plan denied your request. The Plan says 
the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve mechanical traction therapy to be provided by a chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves, per 100 (A4927). 
 
You asked the Plan to pre-approve non-sterile gloves. You say that please look at your records thoroughly. You 
are totally incontinent. The gloves make it easier for your caregivers to clean you up. The Plan denied your 
request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve non-sterile gloves, per 100 (A4927).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that you have fluid on your knee. The Plan denied your 
request. The Plan says you have not tried non-medication treatments. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Orthovisc. Our physician reviewer 
found that you are being treated for knee pain. You note the symptoms for approximately 1 month. The exam 
reveals range of motion 0-115 degrees. There is mild effusion. Medial and lateral joint line tenderness is noted. 
However, detailed documentation is not evident regarding significant osteoarthritis in the left knee. Moreover, 
there has been no recent/updated medical examination to support ongoing subjective complaints and objective 
deficits of the left knee after the previously administered cortisone injections. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the documentation does not support that Orthovisc 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are unable to perform wound care yourself and 
you need SNF services to help you recover. The Plan denied your request. The Plan says  admission to a SNF is 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair (A9270, E0627). 
 
You asked the Plan to pre-approve a lift chair. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a seat lift mechanism is covered if certain criteria are 
met.  
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 lift chair. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the seat lift mechanism is part of the 
treatment plan of the treating practitioner, but the documentation is not clear that this was prescribed to effect 
improvement, arrest or retard deterioration in your condition. The documentation does not support that you are 
completely incapable of standing up from a regular armchair or any chair in their home. You do ambulate. The 
documentation does not support that all the coverage criteria have been met for a lift chair/ seat lift mechanism. 
 
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 lift chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lift chair (A9270, E0627).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory failure from asthma and obesity hypoventilation syndrome. She is being treated with bi-level positive airway 
pressure (BiPAP) therapy. The enrollee's diagnoses do not meet the criteria for coverage of the requested 
ventilator. The services are not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, it is the Plans responsibility to show that its decision to deny 
coverage is correct. Records from a Plan provider are considered to be within the control of the Plan. In cases 
where the Plan has not supplied records from a Plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a Plans 
failure to obtain records that are within the Plans control. The Plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the CGM. Therefore, we decided that the Plan 
has to pre-approve a continuous glucose monitor (CGM).  
 
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 hand break installation for your car. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve hand break installation for your car.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on February 2, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis codes are not valid. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with diagnosis codes that 
exclude each other. 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 pay for the emergency room (ER) 
services rendered on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81455) provided on January 30, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that this test was medically necessary and 
appropriate. The Plan denied your request. The Plan says this claim was submitted with inappropriate diagnosis 
codes. 
 
The Plan must follow Medicare rules. Medicare rules say that some diagnosis codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory testing have not been met. Specifically, this claim was submitted with diagnosis codes 
C56.1 (malignant neoplasm of right ovary) and C56.2 (malignant neoplasm of left ovary), indicating that the condition is bilateral. However, C56.3 (malignant neoplasm of bilateral ovaries) is a valid code which should 
be reported in this case instead. Therefore, we decided that the Plan does not have to pay for laboratory testing 
(81455) provided on January 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on November 22, 2022. 
 
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says the appropriate modifier 
was not 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. 
 
We find that payment for CPT code 73560 is not supported in the medical record. Specifically, code 73560 was 
not billed with the appropriate anatomical modifier required in this case. Based on this information, we decided 
that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not 
have to pay for the x-ray provided on November 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy. 
 
You asked the Plan to pre-approve wireless capsule endoscopy. You say that a wireless capsule endoscopy is 
medically necessary. The Plan denied your request. The Plan says the requested wireless capsule endoscopy is 
not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that a wireless capsule endoscopy is covered when the 
criteria listed in the Medicare rules section of this decision are met.  
 
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 wireless capsule endoscopy. Our 
reviewer says that the requested wireless capsule endoscopy is not considered medically necessary in this case. 
Our physician reviewer found that based on the provided records, you are asymptomatic relative to the 
gastrointestinal (GI) tract, you have no cutaneous manifestations associated with a polyposis syndrome nor, 
despite your family history, has one been identified by genetic testing based on provided records. There is very 
little likelihood of Peutz-Jeghers syndrome, nor of a PTEN hamartoma tumor syndrome (e.g. Cowden 
syndrome) to support at this time that wireless capsule endoscopy is reasonable and necessary nor that meets 
coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable oxygen 
concentrator so that you can go places. The Plan denied your request. The Plan says this is considered duplicate 
equipment. 
 
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 portable oxygen concentrator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization (36247). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. 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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental therapy at this time. Therefore, the 
request is deemed not 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization (36247).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Eventify. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
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 Evenity. Our reviewer says that Evenity 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug Forteo. Also, there is no indication that the Plan's required drug would likely be less effective 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673 and E0673) 
provided on January 16, 2023.. 
 
You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. 
The Plan says these devices are not covered by Medicare when the place of service is an ambulatory surgical 
center. 
 
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 pay for a pneumatic compression device (E0673 and E0673) provided on January 16, 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 you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval 
of a ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
which is a modality which could be provided by a bilevel positive airway pressure (BiPAP) device with 
AVAPS and a back-up rate. Provided records do not document trial and failure of a BiPAP device with 
AVAPS and a back-up rate. 
 
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).