Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent for subcutaneous injection. 
 
You asked the Plan to pre-approve the medication. You say that this medication is needed. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 The drug requested is formulated for self-injection and is not among the types of self-administered drugs 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent for 
subcutaneous injection.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for LTACH service is correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the enrollee appears to be unstable and requires additional acute care that can be 
safely provided at the current facility until more stable and appropriate for transfer. The enrollee does not 
require services at the LTACH that are not already available at the current facility. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with a power tilt 
and recline seating system.  
 
You asked the Plan to pre-approve the requested PWC. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says the criteria for the requested PWC are not met.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options may 
only be covered when the enrollee meets criteria for a power tilt and power recline seating system. 
 
 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 PWC. Our reviewer says 
that the documentation does not show that the criteria for the requested PWC base are met.  Our physician 
reviewer found the provided records do not support that the enrollee is high risk for skin breakdown, has a 
history of pressure ulcer(s) or has had skin flap surgery. Records do not document the enrollee performs 
bladder self-catheterization and is unable to transfer independently. Records from the enrollee's treating 
medical provider do not support that the enrollee has increased muscle tone or spasticity to meet criteria for the 
power tilt and/or recline or the multiple power option base. As the requested wheelchair base does not meet 
Medicare coverage criteria, the requested accessories are not covered. 
 
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 PWC have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 3 power wheelchair (PWC) with a power tilt and recline seating system.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy visits (G0151). 
 
You asked the Plan to pre-approve the aide services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the additional visits are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
  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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that the enrollee 
does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order 
to improve the enrollees condition, perform a maintenance program to maintain enrollees condition and/or 
prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations.  The requested home health services are not 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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional home health physical therapy visits (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve 100 additional routine transportation trips. 
 
You asked the Plan to approve these services. You say that you disagree with the deial. The Plan denied your 
request. The Plan says you have exhausted the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 100 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used all 100 
one-way trips allowed by your supplemental routine transportation benefit. Based on this information, we 
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to approve 100 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromonitoring services provided on March 7, 2022, 
billed with codes 95908, 95886, and 95937. 
 
You asked the Plan to pay for the neuromonitoring services as billed. You say that this was billed correctly and 
should be paid.  The Plan denied your request. The Plan says these codes are 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 code 95908 is nerve conduction studies; 3-4 studies. The 
definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 
studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for 
primary procedure). The definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 
 
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 neuromonitoring services as billed. Our 
reviewer says that the documentation does not support the billed codes.  Our reviewer found the provided 
records in this case document intra-operative neuromonitoring during an L4-L5 decompression and fusion 
procedure; however, there is no documentation of the codes at issue. 
 
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 neuromonitoring services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the neuromonitoring services provided on March 7, 2022, billed 
with codes 95908, 95886, and 95937.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is still having trouble getting around 
and could use therapy services to get back to their prior level of function. The Plan denied your request. The 
Plan says the enrollee does not appear to have daily skilled service needs. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse, nor does the enrollee have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist.  
 
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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alcohol and/or drug services; methadone administration 
and/or service (H0020) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the drug treatment services. You say that the services are medically 
necessary. You are on Methadone and go to the facility for assistance. You were previously approved last year 
July, 2022. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 
Alcohol and/or drug services; methadone administration and/or service (H0020) to be provided by an out-of-
network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 23, 2022, to July 8, 
2022.  
You asked the Plan to pay for home health services. You say that these services were billed correctly. The Plan 
denied your request. The Plan says diagnosis codes I69.391 and I69.322 are not supported by records. 
 
The Plan follows Medicare rules. Medicare rules state that certain data elements are required for payment of 
home health 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 pay for home health services. Our reviewer says that 
these services do not meet criteria for payment. Our physician reviewer found the documentation does not 
support the correct patient driven payment model (PDPM) health insurance prospective payment system 
(HIPPS) code was submitted by the provider. The documentation does not support that the enrollee actively 
required treatment for diagnoses include codes I69.391 or I69.322. The partial adjustment to the HIPPS code 
was appropriate. 
 
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 pay for home health services provided from June 23, 2022, to July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulator generator (C1767).  
 
You asked the Plan to pre-approve an implantable neurostimulator generator. The Plan denied your request. 
The Plan says under Medicare guidelines, your request is not medically necessary because the records show the 
enrollee does not have demonstrated pain relief with a temporarily implanted electrode.  
 The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria in the rules 
section of this letter 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 an implantable neurostimulator 
generator. Our reviewer says that the service is not medically necessary. Our physician reviewer found that this 
enrollee has chronic low back pain. The enrollee has failed conservative therapy including physical therapy and 
epidural steroid injections. There is no surgical consultation documented. The enrollee had a trial of a spinal 
cord stimulator (SCS) but the results are not clearly documented. The results of the temporary trial need to be 
clearly documented before proceeding to permanent implantation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable neurostimulator generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an implantable neurostimulator generator (C1767).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0670). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee 
has unique characteristics that meet the medical necessity policy for the purchase of E0652 and E0670. The 
Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced 
lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either 
E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0670).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with nivolumab and ipilimumab.  
 
You asked the Plan to pre-approve the requested combination treatment. You say that the services are 
medically necessary. The Plan denied your request. The Plan says this request was denied because the 
requested use of this drug in the enrollee's medical situation is not a medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 requested combination treatment. 
Our reviewer says that the requested combination treatment is not considered reasonable and necessary in this 
case.  Our physician reviewer found the enrollee is suffering from small cell lung cancer with the provider citing a carboplatin shortage. The combination treatment is not FDA-approved for this condition as the 
combination was not shown to increase overall survival over using nivolumab alone. There are other 
combination therapies that may be more appropriate given carboplatin shortage. There is also no support for 
this treatment in the major drug compendia or Medicare-approved research journals. 
 
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 combination treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve treatment with nivolumab and ipilimumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA) of nerves (64635). 
 
You asked the Plan to pre-approve the RFA procedure. You say that you are requesting an appeal for the 
denied procedure of repeat bilateral L5/S1 RFA. The Plan denied your request. The Plan says under Medicare 
guidelines, the request is not medically necessary because the records show the enrollee has met the frequency 
limitations.  
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The enrollee has had two previous radiofrequency ablations within 
the past 12 months on September 15, 2022, and January 31, 2023. Based on this information, we decided that 
Medicare rules for coverage of the RFA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the radiofrequency ablation (RFA) of nerves (64635).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the serum iron studies (83540, 82728, and 83550) provided 
on November 21, 2022. 
 
You asked the Plan to pay for procedure codes 83540, 82728, and 83550. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 

The Plan must follow Medicare rules. Medicare rules say that that serum iron studies are coverable when billed 
with a covered diagnosis code. You billed the serum iron studies in dispute with diagnosis code R53.82. 
Diagnosis code R53.82 is not listed in the controlling Medicare policy as a covered diagnosis for this service. 
Based on this information, we decided that Medicare rules for coverage of codes 83540, 82728, and 83550 
have not been met. Therefore, we decided that the Plan does not have to pay for the serum iron studies (83540, 
82728, and 83550) provided on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insert for pneumatic propulsion tire (removable), any type 
(E2213) and pneumatic propulsion tire, any size (E2211).  
 
You asked the Plan to pay for the wheelchair accessories. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested. The Plan denied your 
request. The Plan says these items do not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   

We looked at the file and Medicare rules. Pneumatic propulsion tires are not medically necessary for in home 
use. Based on this information, we decided that Medicare rules for coverage of the wheelchair accessories have 
not been met. Therefore, we decided that the Plan does not have to pay for insert for pneumatic propulsion tire 
(removable), any type (E2213) and pneumatic propulsion tire, any size (E2211).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28285 for date of service December 6, 2022. 
 
You asked the Plan to pay for procedure code 28285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim does not clearly identify an amendment. 
 
The Plan must follow Medicare rules. Medicare rules say that a claim containing amendments must clearly and 
permanently identify any amendment. 
 
We looked at the file and Medicare rules. Review of the file shows that the claim does not clearly and 
permanently identify an amendment. This code is not payable as billed. Based on this information, we decided 
that Medicare rules for coverage of procedure code 28285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 28285 for date of service December 6, 2022.