Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positioning wheelchair back cushion identified with code 
E2620 provided on December 8, 2022. 
 
You asked the Plan to pay for the positioning wheelchair back cushion. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says service exceeds recommended frequency per 
Medicare 
guidelines. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 The file shows that the enrollee had a positioning wheelchair back cushion at the time the positioning 
wheelchair back cushion was received. Review of the file shows that the enrollee received a back cushion 
identified with code E2615 on March 29, 2019. The back cushion the enrollee already had serves the same 
purpose as the rendered positioning wheelchair back cushion. Therefore, we decided that the Plan does not 
have to pay for the positioning wheelchair back cushion identified with code E2620 provided on December 8, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 27, 2022, to 
November 11, 2022. 
 You asked the Plan to pay for the home health services. You say that you were given no definitive reason for 
this denial. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 27, 2022. The NOA was not received by the Plan until January 11, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 27, 2022, to November 11, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380).  
 You asked the Plan to pre-approve Entyvio. You say that the request is medically necessary. The Plan denied 
your request. The Plan says 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 Entyvio. Our reviewer says that the 
criteria for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial of 
Stelara before they will approve Entyvio. In this case, the enrollee has not tried and failed Stelara. There is no 
documentation provided indicating that the Plan's required drug would likely be less effective or 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Psychological and Neuropsychological Assessment. 
 
You asked the Plan to pre-approve the Psychological and Neuropsychological Assessment. You say that the 
service is medically necessary. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Psychological and Neuropsychological testing is 
considered not reasonable and necessary when used as screening tests given to the individual or to general 
populations. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Psychological and Neuropsychological Assessment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Psychological and Neuropsychological Assessment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on December 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit".  
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 use of code 99223 is 
not supported by the records provided. Our reviewer found that there was no comprehensive history 
documented in the records. 
 
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 the services (99223) provided on December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that if you do not receive the LTACH level 
of care it will be detrimental to your health. The Plan denied your request. The Plan says you are currently 
receiving the appropriate level of care and do not require transfer to an LTACH. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to get back 
to being independent. The Plan denied your request. The Plan says the Medicare criteria for IRF admission was 
not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 respiratory failure and pleural effusion. Medical problems are stable. There are 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. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging (78815). 
 
You asked the Plan to pre-approve a Positron emission tomography (PET). You say that  The Plan denied your 
request. The Plan says the enrollee is diagnosed with multiple myeloma, has not achieved remission, and scan 
is needed to show lesions. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 Positron emission tomography (PET). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found criteria not met as 
has had at least 3 prior  Positron emission tomography with concurrently acquired computed tomography for 
myeloma assessment disease can be done by the height of the M protein deny as criteria not met 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Positron emission tomography (PET) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78815).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  LTACH services is the appropriate level 
of care for the enrollee. The Plan denied your request. The Plan says  the Medicare criteria for LTACH 
admission was not met. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6241) for tooth #5 and #7 and retainer crowns 
(D6751) for tooth #3, #4, and #6. 
 
You asked the Plan to pre-approve the dental services. You say that you do not have front teeth and you are not 
able to eat. The Plan denied your request. The Plan says the enrollee is missing multiple teeth and their dentist 
recommends an upper denture. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our reviewer says 
that the treatment required is not reasonable or medically necessary. Our physician reviewer found that the 
bone loss on teeth #3, #4, and #6 is greater than 50%. Tooth #4 is broken to the level of the bone and is not 
restorable. Other teeth in the arch are in degrading condition. Teeth #8 and #11 bridge abutments are failing 
with recurrent decay and failing margins. Teeth #13 and the remnant of #14 root is broken to the gingiva. The 
upper arch is not reasonably restorable and would need a full upper denture. 
 
The requested abutments are in poor condition and exhibit extensive bone loss and structural loss making them 
unsuitable as abutments. As there are several missing posterior teeth in the arch, and most of the remaining 
teeth are not reasonably salvageable, the requested treatment would not meet plan criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve pontics (D6241) for tooth #5 and #7 and retainer crowns (D6751) for tooth #3, #4, and 
#6.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2311), expandable 
controller (E2377), harness (E2313), and standard joystick with color screen (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair accessories. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has adequate strength the manage standard power drives. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection (E2311), expandable controller (E2377), harness 
(E2313), and standard joystick with color screen (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl (J0896). 
 
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says the enrollee did not 
fulfill the criteria that are requisite for this prescription. 
 
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 Reblozyl. Our reviewer says that 
Reblozyl is not medically reasonable and necessary for the enrollee. Our physician reviewer found Reblozyl is 
FDA-approved for the treatment of anemia in myelodysplastic syndrome (MDS) with ring sideroblasts and 
thrombocytosis after erythropoiesis stimulating agent failure and requirement for 2 or more packed red blood 
cell units over 8 weeks. Provided records in this case do not document erythropoiesis stimulating agent failure. 
Our reviewer found that the use of Reblozyl for anemia in MDS without documentation of erythropoiesis 
stimulating agent failure is not supported by one of the major drug compendia or by clinical research that 
appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. The use is not 
indicated, supported or recommended in any of the compendia. Our physician reviewer also found that the use 
of Reblozyl for anemia in MDS without documentation of erythropoiesis stimulating agent failure does not 
meet Medicare criteria for safe and effective and otherwise reasonable and necessary for this 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl (J0896).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring Active Compression Garment 
system. 
 
You asked the Plan to pre-approve a Koya Dayspring Active Compression Garment system. You say that the 
requested Koya Dayspring Active Compression Garment system is medically necessary. The Plan denied your 
request. The Plan says the requested Koya Dayspring Active Compression Garment system is not medically 
necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 Koya Dayspring Active Compression 
Garment system. Our reviewer says that the requested Koya Dayspring Active Compression Garment system is 
not medically necessary. Our physician reviewer found the record does not indicate appropriate services are not 
available in network. 
 
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 Koya Dayspring Active Compression Garment system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Koya Dayspring Active Compression 
Garment system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthetic foot (L5981 and L5968). 
 
You asked the Plan to pre-approve the prosthetic foot. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the requested items exceed the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 prosthetic foot. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found the physical therapy and physician 
progress notes do not support that this enrollee, who uses an assistive device to ambulate,  is a K3 level 
ambulator.  
 
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 prosthetic foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the prosthetic foot (L5981 and L5968).