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

 
We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device and a 
humidifier, heated, used with the positive airway pressure device. 
 
You asked the Plan to pre-approve a CPAP device and a humidifier. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that they were unable to make a 
determination within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, it is the Plans responsibility to show that its decision to deny 
coverage is correct. Records from a Plan provider are considered to be within the control of the Plan. In cases 
where the Plan has not supplied records from a Plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a Plans 
failure to obtain records that are within the Plans control. The Plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the CPAP device. Therefore, we decided that 
the Plan has to pre-approve a continuous positive airway pressure (CPAP) device and a humidifier, heated, 
used with the positive airway pressure device.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Venofer before it will approve Injectafer. 
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Injectafer. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Venofer. The record does not show that this drug 
would likely be less effective and/or have adverse effecst 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Injectafer.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic and acupuncture services coded with 
procedure codes 99205, 99204, 99203, 99202, 99215, 99214, 99213, 99212, 98940, 98941, 98942, 98943, 
97140 and 97810. 
 
You asked the Plan to pre-approve the chiropractic services. You say that the records provided support the 
necessity of the requested service. The Plan denied your request. The Plan says the diagnosis code M54.2 
(cervicalgia) is not a covered diagnosis for the requested services. Acupuncture is not covered when rendered 
by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules also say that acupuncture services are not 
covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited 
coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day 
period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare 
acupuncture benefit. As such, the Plans rules apply in this case.  
 
The records show that the service at issue is not manual manipulation of the spine and the rules for coverage of 
the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the chiropractic and acupuncture services coded with procedure codes 99205, 99204, 99203, 99202, 99215, 
99214, 99213, 99212, 98940, 98941, 98942, 98943, 97140 and 97810.
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 is unable to function and needs 
rehabilitation due to current medical condition. The Plan denied your request. The Plan says the Medicare 
requirements for an IRF admission are not met and the enrollee's needs can be met at a lower level of care. 
 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says you are medically stable, IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110 and 97530) provided on January 18, 
2023. 
 
You asked the Plan to pay for therapy services. You say that these services were pre-approved and should be 
paid. The Plan denied your request. The Plan says this claim was submitted with incompatible diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, this claim was submitted with diagnosis codes 
R26.9 (unspecified abnormalities of gait and mobility) and R27.0 (ataxia, unspecified). However, codes with in 
the R26 code range have an Excludes1 note with codes within the R27 code range. This means that these two 
codes should not be reported together. Therefore, we decided that the Plan does not have to pay for therapy 
services (97110 and 97530) provided on January 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the medical 
necessity criteria for admission to an acute rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis provided on August 19, 2022. 
 
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says this was not provided 
for use in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home, as it was billed with an outpatient place of 
service. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the 
home. Therefore, we decided that the Plan does not have to pay for the knee orthosis provided on August 19, 
2022.
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 medical records were submitted to support 
the reconsideration of the denied home ventilator used with non-invasive interface. The Plan denied your 
request. The Plan says there must be enough detailed information in the medical record to support the use of a 
home ventilator instead of a continuous positive airway pressure (CPAP) device or a bi-level positive airway 
pressure (BiPAP) device. The enrollee does not meet criteria for approval. 
 
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. 
 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 reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in an average volume assured pressure support (AVAPS) 
mode which is a modality which could be provided by a BiPAP device with AVAPS and a back-up rate. 
Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve armodafinil tablets. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been on this medication for 
two years. You say that denying this medication will go against medical advice and the enrollee will 
significantly decline from their stable state. 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 armodafinil tablets.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyio. 
 You asked the Plan to pre-approve Entyio. 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. 
 
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 Entyio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no indication that the plan's required drugs 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 Entyio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Entyio.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy electrical pump, 
stationary or portable (E2402) and a wound care set, for negative pressure wound therapy electrical pump, 
includes all supplies and accessories (A6550). 
 
You asked the Plan to pre-approve negative pressure wound therapy and a wound care set. You say that you 
disagree with the denial and request reconsideration. The Plan denied your request. The Plan says the records 
do not show that the enrollee has been appropriately turned and positioned or that she has used a group 2 or 3 
support surface. The request is 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 negative pressure wound therapy and a 
wound care set. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has a chronic sacral wound. She 
underwent operative debridement on June 1, 2023. A fax sent on June 12, 2023, contained an unsigned, 
undated order for negative pressure wound therapy. The provided records do not show that the enrollee has 
been appropriately turned and positioned or that she has used a group 2 or 3 support surface. The records no not 
contain a completed standard written order. The review has determined that the enrollee does not meet criteria 
for the requested items. The items 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 negative pressure wound therapy and a wound care set have not been met. 
Therefore, we decided that the Plan does not have to pre-approve negative pressure wound therapy electrical 
pump, stationary or portable (E2402) and a wound care set, for negative pressure wound therapy electrical 
pump, includes all supplies and accessories (A6550).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroscopy. 
 
You asked the Plan to pre-approve a knee arthroscopy. You say that a knee arthroscopy is medically necessary. 
The Plan denied your request. The Plan says the requested knee arthroscopy is 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 a knee arthroscopy. Our reviewer says 
that the requested knee arthroscopy is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was being treated for a medial meniscus tear. The enrollee presented 
with right knee pain and has had knee pain and swelling since overexerting on May 11, 2023. The enrollee has 
an ache along the medial and posterior knee. The exam reveals 2+ effusion. The enrollees knee comes to just 
about full extension and flexion up to 130 degrees. There is tenderness along the medial joint line and had extreme pain medially with McMurrays. However, detailed documentation regarding a trial and failure of 
recent, reasonable, comprehensive, less invasive conservative care measures is not evident. The noted 
examination did not corroborate any knee instability or mechanical symptoms. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No 
compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested knee arthroscopy is not medically reasonable or 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 a knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee arthroscopy.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that an IRF 
admission 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollee's conditions is in fact complex, fragile, and proper long-term dispositions need to be 
carefully considered. It is expected that the enrollee will participate in and benefit from services to include at 
minimum physical therapy, occupational therapy, speech-language pathologist, physician management for their 
cardiac, neurological issues and careful case management coordination to see how the enrollee can return home 
safely. Therefore, the requested inpatient rehab facility admission is approved.  
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT services to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve PT services. You say that the enrollee requires a therapy evaluation and 
services to regain strength. The Plan denied your request. The Plan says the requested services can be 
performed by an in-network provider. 
 
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 
PT services to be provided by an out-of-network (OON) provider.