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

 
We decided that the Plan does not have to pre-approve blood glucose test or reagent strips (A4253).  
 
You asked the Plan to pre-approve the blood glucose test or reagent strips. You say that the items should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the items denied correctly 
as they must be obtained from a preferred brand and through a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage (MA) plans may specify 
brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the 
DME to only those preferred brands and manufacturers, as long as they ensure that enrollees have access to all 
medically necessary (including non- preferred) DME products or brands. You can find this information in the 
Centers for Medicare and Medicaid Services Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual Chapter 4, 10.12.2..  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the blood glucose test or reagent strips have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the blood glucose test or reagent strips (A4253).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gen-Syl Injection-3.  
You asked the Plan to pre-approve Gen-Syl Injection-3. The Plan denied your request. The Plan says the 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 Gen-Syl Injection-3. Our reviewer says 
that the requested Gen-Syl Injection-3 is not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has not tried and failed the required drug. There is no documentation provided 
indicating that the Plans required drug 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 Gen-Syl Injection-3 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Gen-Syl Injection-3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair. 
 
You asked the Plan to pre-approve wheelchair. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this durable medical equipment is not being requested for use in the 
home. 
 
The Plan must follow Medicare rules. Medicare rules say that separate Part B payment is not made for DME if 
an individual is a patient in a hospital or skilled nursing facility institution.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
ultra-lightweight manual wheelchair.
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 reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says intensive rehabilitation service is 
not medically reasonable or necessary based on Medicare guidelines.  
 
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 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 pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675, E0673).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on December 
23, 2022. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF liquid 
biopsy (81455) provided on December 23, 2022.
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 medically necessary for the 
enrollee's recovery. The Plan denied your request. The Plan says the enrollee's records do not show that they 
need an intensive team for their 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 intensive rehabilitation. The enrollee does not have 
complex or intensive rehabilitation needs. IRF admission criteria is 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 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: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the enrollee has spine metastasis and is requiring 
radiation. The Plan denied your request. The Plan says no need for daily IGRT is apparent. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this IGRT is simply being used as routine practice, as there does not seem to be any exceptional 
circumstances with this enrollee necessitating the need for IGRT and the records do not justify the need for 
IGRT. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 28, 
2022, through August 31, 2022. 
 
 
  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department with chest pain and shortness of 
breath. The echocardiogram was normal, cardiac catheterization was normal, her vital signs were stable, and 
she was not in any acute distress. She was diagnosed with acute congestive heart failure due to atrial fibrillation 
with rapid ventricular response and received antiarrhythmics, anticoagulants, digitalis, diuresis, calcium 
channel blockers, analgesics, vasodilators, antiplatelets, anti-emetic, and non-steroidal anti-inflammatory drugs 
with benefit initially. The workup ruled out severe infection, acute coronary syndrome, pulmonary embolism, 
and other serious conditions that might warrant a prolonged hospital stay. Due to low severity and stable 
hemodynamics, it was not expected that the enrollee would require hospital care that would likely cross two 
midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from August 28, 2022, through August 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional episodic home health physical therapy. 
 You asked the Plan to pre-approve home health services. You say that the physical therapy is needed. 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 the 
documentation does not support that you require additional skilled nursing services or skilled rehabilitation 
services to provide treatment that is medically necessary. You do not require additional skilled nursing or 
rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition, 
perform a maintenance program to maintain your condition, and/or prevent deterioration. You have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional episodic home health physical therapy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you need continued rehabilitation to regain mobility. 
The Plan denied your request. The Plan says continued admission in the SNF does not meet the requirements 
for approval.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Viva Lift Ultra.  
You asked the Plan to pre-approve a Viva Lift Ultra. You say that the requested lift chair is necessary due to 
your condition which has required multiple hospitalizations. The Plan denied your request. The Plan says the 
requested lift chair is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Viva Lift Ultra have not been met. Specifically, the treating physician did not submit sufficient 
records to support that coverage criteria for the seat lift are met. Therefore, we decided that the Plan does not 
have to pre-approve a Viva Lift Ultra.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable for transfer and as it would not be clinically advantageous. Completion of treatment at the 
current facility is recommended.  
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: 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 you are not ready to leave because you and your 
doctors feel that it is not safe for you to return home yet. The Plan denied your request. The Plan says you can 
continue your rehabilitation at another level of care.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the omalizumab injections provided on 
May 10, 2022, to August 5, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you cannot afford the coinsurance. 
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 drugs covered under Medicare Part B.  
 
 
 
 You have been asked to pay up to 20% coinsurance for the injection provided on June 16, 2022. You have been 
asked to pay $411.14. You have also been asked to pay $481.23, which is 20% coinsurance of the allowed 
amount for the injections provided on May 10, 2022, and August 5, 2022 ($2,406.15 allowed amount x 20% = 
$481.23). 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 omalizumab injections provided on May 10, 2022, to August 5, 
2022.
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 you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says criteria for admission to the SNF have not been 
met.  
 
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. The enrollees care needs can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.