Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on April 07, 
2022. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on April 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hercules patient repositioner (E1399). 
 
You asked the Plan to pre-approve a bed repositioning device. You say that the enrollee needs a lift to help her 
sit up or get out of the bed. The Plan denied your request. The Plan says the bed repositioning device is solely 
for caregiver convenience.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The records show 
the enrollee already has a Hoyer lift. The requested device is not covered by Medicare or the Plan. Therefore, 
we decided that the Plan does not have to pre-approve a Hercules patient repositioner (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Topotecan and Alymsys. 
 
You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 medication. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of recurrent stage IV uterine papillary serous carcinoma and has undergone surgical treatment 
and multiple courses of adjuvant chemotherapy. The Food and Drug Administration (FDA) has not stated that 
the requested drug regimen is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug regimen in the enrollee's 
clinical situation. No literature from Medicare approved cancer journals were submitted for review. 
 
 
  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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Topotecan and Alymsys.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of implant body (D6100). 
 
You asked the Plan to pre-approve the implant removal. You say that you have been having pain and infection 
with drainage. You say x-rays determined that it is medically necessary to get the implant removed. The Plan 
denied your request. The Plan says this implant service is not a covered benefit under the plan. 
 
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. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical removal of implant body (D6100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee is not a candidate for a bilevel positive 
airway pressure (BiPAP) device. The Plan denied your request. The Plan says a ventilator is not covered by 
Medicare for this purpose and the documentation does not support that a bilevel positive airway pressure 
(BiPAP) device would not meet the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. 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 
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 the 
documentation doesnt support that the member requires additional skilled nursing services. 
 
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 home health 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 the enrollee remains at an increased fall risk and 
would benefit from subacute rehabilitation to decrease numerous falls, morbidity, mortality and recurrent 
hospital admissions. The Plan denied your request. The Plan says there are no ongoing skilled nursing needs. 
 
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 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: 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 there would be more services at the requested 
facility. The Plan denied your request. The Plan says you do not meet the criteria for admission to an IRF. 
 
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 you do not require treatment by multiple therapies. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T6 kyphoplasty (22515). 
 You asked the Plan to pre-approve T6 kyphoplasty. 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 PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP) is covered in patients with osteoporotic VCF when certain 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 T6 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documented trial of fracture 
bracing. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T6 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T6 kyphoplasty (22515).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CT scan of the chest. We decided that the Plan does not have to 
pre-approve CT scans of the abdomen and pelvis.  
 
You asked the Plan to pre-approve CT scans of the chest, abdomen, and pelvis. You say that the requested CT 
scans are medically necessary. The Plan says that the medical records do not show a reason why additional CT 
scans are needed. 
 
  We decided that the Plan has to pre-approve a CT scan of the chest.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the chest. Our physician 
reviewer found that the enrollee has a history of possible pulmonary fibrosis and shortness of breath; Thus, a 
CT scan of the chest is reasonable and necessary to look for interstitial lung disease. 
 
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 CT scan of the chest has been met. Therefore, we decided that the Plan has to 
pre-approve a CT scan of the chest.  
 
We also decided that the Plan does not have to pre-approve CT scans of the abdomen and pelvis. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CT scans of the abdomen and pelvis. 
Our reviewer says the submitted records do not show the rationale or medical necessity for the CT of the 
abdomen and pelvis. The enrollees abdominal aorta has been described as normal and the abdominal physical 
exam was negative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve CT scans of the abdomen and pelvis. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for a new patient (99202), and federally 
qualified health center (FQHC) visit, new patient (G0466) provided on October 6, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the $157 charge you are being asked to pay 
for an office visit is totally inappropriate. You also say that you should not have to pay more than the required 
maximum office visit charge of $60. The Plan denied your request. The Plan says this claim was processed 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been 
met. The Evidence of Coverage clearly shows that there is a $60 copayment for out-of-network specialist 
services. This is a contractual obligation you agreed to when you enrolled in the Plans dental coverage. 
Additionally, payment cannot be made for more than one new patient visit by the same provider on a single 
date of service. Therefore, we decided that the Plan does not have to pay for the office visit for a new patient 
(99202), and federally qualified health center (FQHC) visit, new patient (G0466) provided on October 6, 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 this device is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met.  
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 reviewer says 
that the ventilator is not medically necessary. Our physician reviewer found Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. The records do not show a trial of 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 (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair (K0837) and 
additional items and accessories (codes E0955, E1002, E1028, E2361, and E2604). 
 
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair and additional items and 
accessories. The Plan denied your request. The Plan says this request does not meet the Medicare or health plan 
coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 Single Power Option PWC (such as code 
K0837) is covered if the criteria listed in the Medicare rules section of this letter 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 a group 2 heavy duty power wheelchair 
and additional items and accessories. Our reviewer says that the requested group 2 heavy duty power 
wheelchair and additional items and accessories exceed the enrollee's medical needs. Our physician reviewer 
found the documentation indicates the enrollee has a mobility deficit that impairs mobility related activities of 
daily living in the home. The documentation does indicate that the enrollee can alleviate the mobility deficit 
with a walker. Our reviewer found that while the enrollee may be able to safely operate a power mobility 
device, the documentation does not reveal that the enrollee is at high risk for development of a pressure ulcer, 
utilizes intermittent catheterization for bladder management, or needs a power seating system to manage 
increased tone or spasticity. Our physician reviewer also found that the enrollee does not require a drive control 
interface other than a hand or chin-operated standard proportional joystick (examples include but are not 
limited to head control, sip and puff, switch control). 
 
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 group 2 heavy duty power wheelchair and additional items and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy duty 
power wheelchair (K0837) and additional items and accessories (codes E0955, E1002, E1028, E2361, and 
E2604).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bariatric Umano Ook Snow bed frame and a Bariatric 
Emerg Auto-Emersion therapy mattress (E1399x2). 
 
You asked the Plan to pre-approve a total electric hospital bed and mattress. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says the requested hospital bed is 
not covered; the height  
adjustment feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. The records show the Plan has already approved a heavy-duty extra wide hospital bed. 
Therefore, we decided that the Plan does not have to pre-approve a Bariatric Umano Ook Snow bed frame and 
a Bariatric Emerg Auto-Emersion therapy mattress (E1399x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Botox. 
 
You asked the Plan to pre-approve Botox. You say that you are appealing this denial. The Plan denied your 
request. The Plan says there is insufficient evidence to support botulinum toxin for your condition. 
 
The Plan follows Medicare rules. Medicare rules state that botulinum toxins such as Botox are only covered for 
certain FDA-labeled or off-label indications. 
 
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 Botox. Our reviewer says that you do 
not meet criteria for the requested use of Botox. Our physician reviewer found you have a diagnosis of 
gastroparesis. The Food & Drug Administration (FDA) has not stated that Botox is indicated for your 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of Botox in 
your clinical scenario. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Botox.
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 enrollee requires skilled services and medical 
management. The Plan denied your request. The Plan says the enrollee does not have a daily complex skill 
need. 
 
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 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.