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

 
We decided that the Plan does not have to pre-approve an out-of-network referral for evaluation and treatment. 
 
You asked the Plan to pre-approve the referral. You say that you would like a new doctor. The Plan denied 
your request. The Plan says there are network providers available. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 
an out-of-network referral for evaluation and treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265, E0277). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan 
denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265, E0277).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing visits (G0299). 
 You asked the Plan to pre-approve home health services. You say that the provider is appealing with records. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
has some episodes of tachycardia. The enrollee has received skilled services prior to the recertification. A 
physician visit on October 16, 2023, noted stability as well as a skilled nursing visit on November 14, 2023.  
After receiving a number of skilled nursing visits dating to at least September 2023, the enrollee was stable. 
She did not require continued skilled services. No new intervention was indicated or provided effective 
November 14, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health skilled nursing visits (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network gastroenterologist. 
 
You asked the Plan to pre-approve these services. You say that you have been having pain and want to see the 
specialist as soon as possible. The Plan denied your request. The Plan says the services are available from 
network providers. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 referral to an out-of-network gastroenterologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 93306 performed on July 4, 
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 documentation does not support that the excess units were provided.  
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 code 93306 is "Echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography." 
 
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 records are not consistent with 
two units being rendered, nor is there any supportive rationale for their appropriateness and medical necessity.   
 
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 two units of procedure code 93306 performed on July 4, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 You asked the Plan to pre-approve Evenity. You say that the patient has failed oral bisphosphonates. You also 
say that you are requesting this medication as a once-a-month injection for a year as it has been shown to 
improve the difference between the patient's bone mineral density and 0 (T-score) and reduce the risk of 
fractures. The Plan denied your request. The Plan says the patient does not meet the Part B Step Therapy 
requirements for Evenity. 
 
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 the 
patient does not meet the criteria for coverage. Our physician reviewer found the Plan requires a trial of an 
injectable bisphosphonate (for example, pamidronate, zoledronic acid) before they will approve the requested 
drug. In this case, the patient has not tried and failed the required drugs. Our 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 patient. 
 
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 (J3111).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires a higher level of supervision.  
The Plan denied your request. The Plan says the inpatient rehabilitation facility 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 enrollee has bilateral upper extremity (BUE) strength 4+/5; no tingling or 
numbness in BUE, and full strength and sensation in their bilateral lower extremities. Per the physical therapy 
note on November 27, 2023, a Sara Steady lift device is to be used for all transfers for safety and the enrollee 
requires moderate assistance for ambulation. The enrollee is stable for skilled nursing facility (SNF) level of 
care services. 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 does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the request is not medically necessary. The Plan 
denied your request. The Plan says the request 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment services provided on July 10, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON medication assisted treatment services. You say that other claims have 
paid with the same information, without a referral. The Plan denied your request. The Plan says the OON 
services were not pre-authorized.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
OON service at issue. We found no exception that would require the Plan to pay for these OON services. 
Therefore, we decided that the Plan does not have to pay for medication assisted treatment services provided on 
July 10, 2023, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection, denosumab, Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary to treat the enrollees 
bone density problem due to osteoporosis. The Plan denied your request. The Plan says the records do not show 
that the enrollee has met the Plan's step therapy criteria. 
 
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 Prolia. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan requires a trial of drug an oral or IV bisphosphonates, such as alendronate and 
zoledronic acid before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would 
likely be less effective and/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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the injection, denosumab, Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric hospital bed from an out-of-network 
provider. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide repair your bed. 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 bariatric hospital bed 
from an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, spine, cervical provided on  
March 14, 2023. 
 
You asked the Plan to pay for the radiologic examination, spine, cervical. You say that the services were 
medically necessary. The Plan denied your request. The Plan says this provider is ineligible to bill Medicare, 
Medicare cannot reimburse the Veterans Administration (VA) for care furnished in its facilities to veterans. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare explicitly excludes VA facilities from 
participating in Medicare. 
 
We looked at the file and Medicare rules. Medicare excludes VA facilities from participating in Medicare. 
Based on this information, we decided that Medicare rules for coverage of the radiologic examination, spine, 
cervical have not been met. Therefore, we decided that the Plan does not have to pay for a radiologic 
examination, spine, cervical provided on March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 a VASS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of an L5781 vacuum assisted suspension system for residual limb volume management 
and moisture evacuation systems among lower extremity amputees is unproven and not medically necessary 
due to insufficient evidence of safety and/or efficacy. The requested item is not medically necessary  per Social 
Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. 
 
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 VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum assisted socket system (VASS) (L5781).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) home health skilled nursing visits (G0151, 
G0299). 
 
You asked the Plan to pre-approve home health services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation does not specify any recent medical status, medication or plan of care changes and right lower 
limb wound that is healing open to air thus the records do not show that 12 additional home health skilled 
nursing visits are required to effectively provide treatment, care, and/or services in order to improve the 
enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or 
prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twelve (12) home health skilled nursing visits (G0151, G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 90 Tegaderm film (A4649) 90 sterile gloves (A4649) 65 
nonsterile gloves (A4649) and 45 foley anchor (A4649). 
 
You asked the Plan to pre-approve the miscellaneous surgical supplies. You say that these supplies listed 
beyond the enrollee's kits are most definitely necessary each month. A4649 is a bundled code. The Plan denied 
your request. The Plan says additional supplies should be billed separately not with bundle code or 
miscellaneous code 
 
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 code A4649 is surgical supply; miscellaneous. 
 
We find that CPT code A4649 is not supported in the medical record. Specifically, as billed this is a 
miscellaneous bundle code, the supplies were provided as requested in the kit using the code. Additional 
supplies should be billed separately not with a bundled code. The most specific code must be used when 
available. Tegaderm film is correctly coded as A6257. Sterile gloves are correctly coded as A4930. Nonsterile 
gloves are correctly coded as A4927. Foley anchor is correctly coded as A4333. Based on this information, we 
decided that Medicare rules for coverage of the miscellaneous surgical supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 90 Tegaderm film (A4649) 90 sterile gloves (A4649) 65 
nonsterile gloves (A4649) and 45 foley anchor (A4649).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Life2000 for 9 months (E0466). 
 
You asked the Plan to pre-approve a Life2000 for 9 months. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
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 Life2000 for 9 months. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the enrollee has been using and 
benefiting from the Life2000 and to withdrawal this therapy at this time would be substandard of care. The 
enrollee has been compliant with Life2000 since 2022. Hence, continued life2000 would be best practice for 
this enrollee given 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 a Life2000 for 9 months have been met. Therefore, we decided that the Plan has 
to pre-approve a Life2000 for 9 months (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.