Persius/hicric huggingface dataset:
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 needs to return home as soon as 
possible. The Plan denied your request. The Plan says 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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that the 
enrollee will be able to fully participate in  and benefit from  the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from December 1, 2022, to 
December 22, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this provider is an out of network provider and does not meet Medicare's 
standards of non-physician practitioners (other eligible professionals). 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from December 1, 2022, 
to December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you continue to need a ventilator. The Plan 
denied your request. The Plan says a home ventilator is not medically necessary because a bilevel positive 
airway pressure (BiPAP) device may meet your needs. 
 
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 a home ventilator is not medically necessary for you. Our physician reviewer found you have a diagnosis 
of COPD, but there are no pulmonary function tests to assess severity, and no arterial blood gases done while 
stable to document chronic CO2 retention.  If the you did have severe COPD with chronic CO2 retention, you 
may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep.  Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of zoledronic acid before it will approve Prolia. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Prolia. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of zoledronic acid. The record does not show that this 
drug would likely be less effective and/or have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea 
 You asked the Plan to pre-approve Eylea. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee has not met step therapy requirements 
 
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 Eylea. Our reviewer says that Eylea is 
not medically necessary. Our physician reviewer found that the records indicate you have diabetic retinopathy 
with macular edema and the requested medication is a new start. There is no indication that he provided records 
do not indicate that you have tried and failed the Plan's preferred step one alternative. Also, there is no 
indication that the enrollee has a contraindication, to, or would have an adverse effect from the Plan's preferred 
step one alternative. Therefore, the elements of coverage criteria have not been satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea
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 services are necessary based on the enrollee's 
current and functional deficits as well as their multiple comorbidities. The Plan denied your request. The Plan 
says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need intensive therapies. The 
complexity of the enrollee's nursing, rehab, and medical, needs does not require an acute hospital inpatient 
rehab stay with an interdisciplinary approach to rehabilitative care. While the enrollee may benefit from 
physical and occupational therapy, the enrollee's rehab needs can be provided in a lower intensity and alternate 
setting such as in a skilled nursing facility or in-home with services with family support. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit and diagnostic radiology procedures of the lower 
extremities provided on December 15, 2021. 
 
You asked the Plan to pay for the office visit and diagnostic radiology procedures of the lower extremities. You 
say that the claim submission date was prior to the timely filling deadline. The Plan denied your request. The 
Plan says that a corrected claim must be submitted within 1 year from the date of the initial determination or 
redetermination for any reason. 
 
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, the Plan has not provided documentation proving that the claim 
was filed untimely based on Medicare rules. Therefore, we decided that the Plan has to pay for an office visit 
and diagnostic radiology procedures of the lower extremities provided on December 15, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assist socket system (VASS) (L5781), and 
microprocessor-controlled ankle foot system (L5973). 
 
You asked the Plan to pre-approve the upgraded components. You say that the enrollee is a K3 ambulator. The 
Plan denied your request. The Plan says the VASS is experimental and cannot be approved. The Plan also says 
that the documentation does not show why a microprocessor foot is needed. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded prostheses components may be covered 
when they are medically 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 the upgraded components. Our reviewer 
says that the requested upgraded components are not medically necessary. Our physician reviewer found the 
requested microprocessor-controlled ankle foot system exceeds the enrollee's functional needs. The 
documentation notes that the enrollee uses a single crutch ambulating in public. This and the enrollee's 
functional activities do not support K3 level of ambulation. The reviewer found that further research is needed 
with clinical trials that recruit larger sample sizes and report long-term outcome data for the requested elevated 
vacuum suspension system. Therefore, the reviewer found that the upgraded components are 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 upgraded components have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a vacuum assist socket system (VASS) (L5781), and microprocessor-
controlled ankle foot system (L5973).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549 and 
A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 and 
A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549 and A6530.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from June 9, 2020, to June 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 4, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided from 
June 9, 2020, to June 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services 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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that documentation is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. The available documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge for tooth numbers 13, 14, and 15 (D6750 
x 2, D6240). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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. The Plan's dental benefit doesn't cover 
fixed bridges if there are missing posterior teeth on both sides of same arch. 
 
 
  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 criteria for coverage has not been met. Our physician reviewer found that there are numerous missing 
teeth on both sides of the upper arch. Because there are teeth missing on both sides of the arch, the criteria for 
coverage regarding bridges has not been met. Additionally, in order to have adequate support for a bridge, each 
unit of the bridge must have at least 50% of the supporting bone remaining to ensure a favorable long-term 
prognosis of the teeth. Tooth number 15 has less than 15% bone remaining which is inadequate to act as an 
abutment for a fixed bridge.  
 
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 been met. Therefore, we decided that the Plan does not 
have to pre-approve a fixed bridge for tooth numbers 13, 14, and 15 (D6750 x 2, D6240).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological testing evaluation services (codes 96130 
and 96131). 
 
You asked the Plan to pre-approve psychological testing evaluation services. The Plan denied your request. The 
Plan says the requested hours 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 psychological testing evaluation 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on review of the records provided, it was noted this 
enrollee is experiencing radiculopathy in chronic pain. Documentation did not show that the testing would be 
used in treatment of this enrollee. Our reviewer also found that based on review the records provided in the 
information provided there is no evidence that this enrollee requires psychological testing for the treatment of 
Other Spondylosis with radiculopathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological testing evaluation services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve psychological testing evaluation services (codes 96130 and 
96131).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that you are requesting a review of the denial of 
coverage for the Live2000 Ventilator. The Plan denied your request. The Plan says ventilators used to provide 
CPAP (continuous positive airway pressure) or bi- level PAP (positive airway pressure) therapy will be denied 
as not reasonable and 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. 
 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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has severe COPD. There is no documentation of chronic carbon dioxide (CO2) 
retention with an arterial blood gas (ABG) done while stable. The Life2000 system is not a true ventilator, 
because it is not capable of providing full ventilatory support. There is inadequate evidence of the safety and 
efficacy of this device in the treatment of COPD. The Life2000 system 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig (A9282). 
 
You asked the Plan to pre-approve a wig. You say that this wig is medically necessary. The Plan denied your 
request. The Plan says this item is not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service May 14, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service May 14, 2022.