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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 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 home ventilator. Our physician 
reviewer found there is no diagnosis of thoracic restrictive disease or neuromuscular disease. There is no 
arterial blood gas (ABG), done while stable, to document chronic carbon dioxide (CO2) retention. If that is 
present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured 
pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used 
at settings that can be provided with BiPAP. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an OON provider.  
 
You asked the Plan to pre-approve OON SNF care. You say that the enrollee's family is closer to this facility. 
The Plan denied your request. The Plan says in-network providers are 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 
SNF care to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qulipta. 
 
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 Qulipta.   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Kerecis Omega3 MariGen provided on May 9, 2023. 
 
You asked the Plan to pay for Kerecis Omega3 MariGen. You say that Kerecis Omega3 MariGen was 
medically necessary due to slow healing of wound. The Plan denied your request. The Plan says the requested 
Kerecis Omega3 MariGen is experimental and unproven. 
 
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 pay for Kerecis Omega3 MariGen. Our reviewer says that the requested Kerecis Omega3 MariGen is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the Kerecis Omega3 MariGen is not medically necessary for this 
type of surgical wound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis Omega3 MariGen have not been met. Therefore, we decided that the 
Plan does not have to pay for Kerecis Omega3 MariGen provided on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an out-of-network oncology referral. 
 
You asked the Plan to pay for the referral. You say that the requested provider is one of the most 
knowledgeable and experienced physicians specifically for the enrollee's type of cancer. The Plan denied your 
request. The Plan says the provider is out-of-network, and the services can be provided by an in-network 
oncologist. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 referral. Our reviewer says that the requested referral is not medically 
reasonable or necessary. Our physician reviewer found that the plan's denial is medically justified on the basis 
that it is offering adequate care to meet your medical needs through referral to an in-network oncologist. There 
is nothing unique about your condition that would make it medically necessary for you to see the requested out 
of network provider. The plan has shown that they have in-network providers who meets the standards of care 
required for treatment of your condition. 
 
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 referral have not been met.  
 
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 pay for the referral. Therefore, we decided that the Plan does not 
have to pay for an out-of-network oncology referral.
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 SNF stay is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the SNF stay. 
 
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. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 61624 and 75894 rendered on October 4, 2022. 
 
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 that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 61624: 
 
Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to 
occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) 
 
CPT 75894: 
 
Transcatheter therapy, embolization, any method, radiological supervision and interpretation 
 
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 supported by the medical records. Our reviewer found that 61624 and 75894 are supported by 
the medical record. There is a procedure note stating these procedures were performed. The plan's denial states 
that 61624 was performed in the global period of another procedure; however, it was not due to a postoperative 
complication and according to the definition of a global surgical package, CPT 61624 is not included in it. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 61624 and 75894 rendered on October 4, 2022.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for  the urine polymerase chain reaction (PCR) panel testing represented by 
CPT codes 87150, 87481, 87640, 87798, and 87801 provided on February 28, 2021. 
 
You asked the Plan to pay for  the urine polymerase chain reaction (PCR) panel testing represented by CPT 
codes 87150, 87481, 87640, 87798, and 87801. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the services provided were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the urine polymerase chain reaction (PCR) 
panel testing represented by CPT codes 87150, 87481, 87640, 87798, and 87801. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presented with symptoms of burning with urination. The enrollee's care provided 
ordered urine PCR testing which showed presence of E. Coli. The testing was medically appropriate and at 
least as effective as the standard urine culture. The enrollee is elderly and was symptomatic of a urinary tract 
infection, therefore criteria are met and. 
 
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 urine polymerase chain reaction (PCR) panel testing represented by CPT 
codes 87150, 87481, 87640, 87798, and 87801 have been met. Therefore, we decided that the Plan has to pay 
for  the urine polymerase chain reaction (PCR) panel testing represented by CPT codes 87150, 87481, 87640, 
87798, and 87801 provided on February 28, 2021.  
 
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 pre-approve 12 skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that you need assistance with activities of 
daily living. 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 that you do not 
have documented skilled nursing needs. 
 
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 12 skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their 
family practice physician for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied 
your request. The Plan says this is considered experimental and investigational due to insufficient evidence of 
safety and efficacy. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6.  
You asked the Plan to pre-approve a Dexcom G6. You say that the enrollee is treated with diet and oral 
medications. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G6 have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Dexcom G6.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pembrolizumab injections (J7921) 
provided on April 26, 2023, and May 22, 2023. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you cannot afford these medical 
bills with your current income. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs, including chemotherapy drugs.  
 
 You have been asked to pay $2,216.68, which is 20% coinsurance of the allowed amount for the injection 
provided on April 26, 2023 ($11,083.40 allowed amount x 20% coinsurance = $2,216.68). You have also been 
asked to pay $1,581.64 for the injection provided on May 22, 2023, which is less than 20% coinsurance of the 
allowed amount. These items/services fall within the Medicare Part B prescription drugs benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the pembrolizumab injections (J7921) provided on April 
26, 2023, and May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve the service. You say that you want to avoid knee surgery. The Plan denied 
your request. The Plan says current medical literature does not consider this service to be standard medical 
treatment for the enrollee's condition. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental procedure. It is the subject of ongoing clinical trials. 
Therefore, the request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the genicular nerve radiofrequency ablation (64624).
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital. 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. Given there are offered alternatives, LTACH is 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 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 sessions of electroconvulsive therapy. 
 
You asked the Plan to pre-approve 36 sessions of electroconvulsive therapy. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that TMS may be covered if 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 36 sessions of electroconvulsive 
therapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
on the information provided, this enrollee does not meet the clinical criteria for the use of Transcranial 
Magnetic Stimulation (TMS) therapy. There is no documentation as to when the enrollee was given medication 
if it was during this depressive episode. There is a confusion that the enrollee is suffering from Bipolar 
Depression and there was confusion of the enrollee requesting electroconvulsive therapy (ECT) however the 
documentation does not show that the enrollee desires electroconvulsive therapy (ECT). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36 sessions of electroconvulsive therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 36 sessions of electroconvulsive therapy.