Persius/hicric huggingface dataset:
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 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 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a urinary tract infection and rhabdomyolysis after a fall. His medical problems are stable and 
he has no complex nursing or rehabilitation needs. The enrollee 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. There is not a reasonable expectation that this enrollee 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325). 
 You asked the Plan to pre-approve Synvisc. You say that Synvisc is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Synvisc 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 Synvisc. Our reviewer says that 
treatment with Synvisc is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Orthovisc or Supartz FX before they will approve the requested drug. The 
case file does not contain documentation of trial and failure of Orthovisc or Supartz FX. The available 
documentation does not support that Orthovisc or Supartz FX would likely be less effective and/or would likely 
have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Synvisc (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00410 billed for date of service February 22, 
2023. 
 
You asked the Plan to pay for procedure code 00410. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 00410 is included in the payment for 
code 01922. 
 
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 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 procedure code 00410. Our reviewer says that procedure 
code 00410 does not meet criteria for payment. Our reviewer found that the procedure report does not include 
documentation to support that two separate anesthesia codes provided for same session. The billing providers 
are same specialty and billing group. The procedure at issue cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 00410 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 00410 billed for date of service February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compression device (PCD) (E0652) and accessories 
(E0656, E0667). 
 
You asked the Plan to pre-approve the PCD and accessories. The Plan denied your request. The Plan says that 
this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD and accessories are covered for the indications 
established in the applicable LCD. 
 
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 PCD and accessories. Our reviewer 
says that the requested PCD and accessories are medically reasonable and necessary. Our physician reviewer 
found that the enrollee has chronic lower extremity lymphedema and wounds. She has attempted conservative 
measures, including compression garments and is receiving wound care for her lower extremity wounds. The 
documentation indicates that the enrollee trialed a standard pneumatic compression pump, but it caused an 
increase in her truncal edema. Therefore, the requested segmental compression pump with calibrated gradient pressure (E0652) and appliance/accessory (E0656, E0667) are 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 PCD and accessories have been met. Therefore, we decided that the Plan 
has to pre-approve a pneumatic compression device (PCD) (E0652) and accessories (E0656, E0667).  
 
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 procedure code 99490 billed for date of service May 18, 
2021. 
 You asked the Plan to pay for the billed services. You say that the service was provided in accordance with 
applicable regulations. The Plan denied your request. The Plan says there is insufficient documentation to 
corroborate the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, medical records for the date of service have not been 
provided. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99490 billed for date of service 
May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
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).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
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 monoclonal antibodies are covered when specific 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has mild cognitive 
impairment. The records do not indicate that she is enrolled in a clinical trial. The criteria for coverage are not 
met and the Leqembi is 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 Leqembi.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are pending discharge from the hospital and 
your provider has recommended admission to an IRF. The Plan denied your request. The Plan says admission 
to an IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
February 22, 2023. 
 
You asked the Plan to pay for the CGM supplies. You say that the records support the supplies that were 
delivered. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery nor relevant medical records which support medical 
necessity for the supplies provided in this case. Though an order confirmation was included, there is no 
shipping confirmation indicating that the supplies were received by the enrollee. In addition, the medical 
records that were submitted were substantially incomplete with every other page missing. The pages that were 
reviewed did not show any indication of the intent to order a CGM. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the continuous glucose monitor (CGM) supplies provided on February 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that Remicade is medically necessary because the 
enrollee is allergic to sulfa and cannot take sulfasalazine. The Plan denied your request. The Plan says the 
enrollee does not meet the FDA or compendia criteria for use of the Remicade. 
 
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 Remicade. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the FDA has not stated that the requested 
drug is indicated for the enrollee's condition of Collagenous colitis. The use of Remicade is not supported by 
one of the major drug compendia or by clinical research in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on July 23, 2022, to July 27, 2022, 
at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
have billed the services at issue correctly. The Plan denied your request. The Plan says that the DRG billed is 
not appropriate. 
 
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 primary diagnosis code A41.9, defined as Sepsis, 
unspecified organism. 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 reviewer says that inpatient hospital services do not meet criteria for 
payment at the DRG originally billed. Our physician reviewer found that the enrollee had systemic 
inflammatory response with cellulitis confirmed. The provided documentation supports a diagnosis code of 
A41.9. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on July 23, 2022, to July 27, 2022, at the DRG originally billed.  
 
  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 pay for the wheelchair you purchased on February 17, 2023. 
 
You asked the Plan to pay for the wheelchair. The Plan denied your request. The Plan says the wheelchair is 
not covered when purchased. 
 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.  
 
The records show that you purchased a wheelchair on February 17, 2023. The Plan contract says that 
wheelchairs are only covered when rented and not purchased. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay 
for the wheelchair you purchased on February 17, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zinplava. 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
Clostridiodes difficile infection (CDI) and is at high risk of recurrence. The Food and Drug Administration 
(FDA) has stated that the requested drug is indicated to reduce recurrence of CDI in adults who are receiving 
antibacterial drug treatment for CDI and are at a high risk for CDI recurrence. The Zinplava is reasonable and 
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 been met. Therefore, we decided that the Plan has to pre-
approve Zinplava.  
 
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 the home health services provided from August 12, 2022, to 
September 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted timely 
and was processed by the Plan. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 12, 2022, to 
September 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the enrollee suffers with a diagnosis of multiple 
sclerosis and the treating medical professional is the only one qualified to determine exactly what airway 
clearance treatments the enrollee can do and/or tolerate as well as what is effective. The Plan denied your 
request. The Plan says the records received from the provider do not show the enrollee has fluid or mucous in 
her lower airways and they do not show what standard treatments the enrollee has tried to help move the 
mucous in her lower airways. 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 a HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has multiple sclerosis and 
chronic bronchitis. The enrollee was evaluated on March 9, 2023, for fatigue and shortness of breath. It is noted 
that the peak flow meter was thrown away. The enrollee was asking about codeine for cough; this was 
discouraged. The enrollee does not have cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases 
for which a high frequency chest wall oscillation device may be covered. The case file does not contain 
documentation of current use of a mechanical in-exsufflation device with a plan to continue to do so. The 
records do not show well-documented failure of standard treatments to adequately mobilize retained secretions. 
The documentation does not support that the coverage criteria for a high frequency chest wall oscillation device 
have been met in this case. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).