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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and a compression 
sleeve to be provided by an OON provider.  
 
You asked the Plan to pre-approve a compression device and a sleeve accessory. You say that you are 
requesting reconsideration of the denied items. The Plan denied your request. The Plan says the items were not 
approved. 
 
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 
a pneumatic compression device and a compression sleeve to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240). 
 
You asked the Plan to pre-approve the F2 gene analysis, 20210G>A variant. You say that you would like this 
testing done because you do not know your family history and would like to know how to treat your condition 
and what to expect. The Plan denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant parties. 
 
We looked at the file and Medicare rules. This testing is not covered by Medicare or the Plan. Based on this 
information, we decided that Medicare rules for coverage of the F2 gene analysis, 20210G>A variant have not 
been met. Therefore, we decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation 
factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant (81240).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan with concurrently acquired CT of the skull 
base to mid-thigh. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that the requested imaging is medically necessary. 
The Plan denied your request. The Plan says you have had a PET scan to look at your organ and tissue 
function. Repeat PET scans are not supported for treatment planning. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pre-approve a PET/CT scan. Our reviewer says that the 
requested imaging is not medically necessary. Our physician reviewer found that the rules say that a 
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan is covered when medically necessary 
and reasonable to help determine the initial treatment strategy for enrollees suspected of having cancer. In this 
case, a CT scan can be performed initially to follow-up on the nodule and any possible changes of the 
nodule. A PET scan without a follow-up comparison CT of the chest 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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan with concurrently acquired CT of the skull base to mid-thigh.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for a chemical agent used in the diagnostic procedure. 
We decided that the Plan does not have to waive the copayment for a PET scan.  
 You asked the Plan to waive the copayment for a PET scan provided on March 15, 2023.. You say that you are 
requesting the claim to be reviewed and the charge to be removed. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to waive the coinsurance for a chemical agent used in the diagnostic 
procedure.  
 
The rules say a health 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 does not specify the cost share 
for a chemical agent used in a diagnostic procedure. The contract states you pay a 20% coinsurance for surgical 
supplies, splints, and casts. A chemical agent used in a diagnostic radiology procedure does not fall under any 
of these categories. Therefore, we decided that the Plan has to waive the copayment for a chemical agent used 
in the diagnostic procedure.  
 
We also decided that the Plan does not have to waive the copayment for a PET scan. 
 
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 a $90 
copayment for diagnostic radiology services in a providers office or freestanding radiology center, which 
includes a PET scan. Therefore, we decided that the Plan does not have to waive the copayment for a PET scan. 
 
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 home ventilator (continued use). 
 
You asked the Plan to pre-approve home ventilator (continued use). You say that the requested home ventilator 
is medically necessary for the enrollee. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS). 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 home ventilator (continued use). Our 
reviewer says that the home ventilator is not medically necessary. Our physician reviewer found that this 
enrollee has COPD. An arterial blood gas (ABG) shows no evidence of chronic carbon dioxide (CO2) 
retention. The Life2000 system is not a true ventilator because it is not capable of providing full ventilatory 
support. It is intended to be used during activity, and there is inadequate evidence that it is beneficial in the 
treatment of any chronic 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 home ventilator (continued use) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve home ventilator (continued use).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair of a total electric hospital bed. 
 
You asked the Plan to pre-approve the repair of a total electric hospital bed. You say that the service should be 
covered. The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare, 
and therefore, the repair is not covered. 
 
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. Therefore, we decided that the Plan does not have to pre-approve the repair of a total 
electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management provided on February 01, 2023. 
 
You asked the Plan to pay for pain management. You say that you are appealing the claim payment denial. 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 pain management 
provided on February 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 You asked the Plan to pre-approve the injections. You say that the enrollee has been treated with lumbar facet 
joint injection, however the benefit of the injection has been decreasing. The Plan denied your request. The 
Plan says facet joint injections 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 the injections. Our reviewer says that 
facet joint injections are not medically necessary.  Our physician reviewer found that there is no documentation 
of the absence of untreated radiculopathy or neurogenic claudication. Also, there is no non-facet pathology per 
clinical assessment or radiology studies that could explain the source of the enrollee's pain, including but not 
limited to fracture, tumor, infection, or significant deformity. Therefore, the enrollee does not meet the LCD 
coverage criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 sensor kit. The Plan denied your request. The Plan 
says based on the information provided on appeal coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Medical records were not supplied to support the service requested. 
Without the medical records we are unable to determine whether the criteria for coverage have been met. The 
Plan also provided evidence of reasonably attempting to obtain medical records. Based on this information, we 
decided that there is insufficient information in the record to determine if Medicare rules for coverage of the 
Freestyle Libre 2 sensor kit have been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 sensor kit.
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 you are requesting an expedited appeal 
for the denial of an LTACH admission. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving care at the acute hospital that is covered. There are no 
specific needs or additional treatments the enrollee would receive at the LTACH. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you do not agree with the denial of the 
raised toilet seat. The Plan denied your request. The Plan says the requested item is not covered by Medicare or 
the health plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve the requested item. You say that you need the seat raiser to get up safely. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization (GAE). 
 
You asked the Plan to pre-approve the requested services. You say that the treatment will provide long-lasting 
pain relief. The Plan denied your request. The Plan says there is little evidence this is an appropriate service for 
knee arthritis.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has bilateral knee pain from osteoarthritis. She has had steroid injections as 
well as viscosupplementation trials. The request is for embolization of the genicular arteries. This is considered 
experimental/investigational at this time. There are ongoing clinical trials of this procedure and the long-term 
effects are not clear. Therefore, the request is deemed not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular artery embolization (GAE).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy (J3490). 
 
You asked the Plan to pre-approve the medication. 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 Wegovy (J3490).   
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
You asked the Plan to pre-approve Supartz FX. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not support the medical need for this medication. 
 
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 Supartz FX. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee does not have radiographic 
evidence of osteophytes in the knee joint, sclerosis in bone adjacent to the knee, or joint space narrowing. The 
review has determined that the documentation does not support that the Supartz FX is medically reasonable or 
necessary for the enrollee. The documentation does not support that the Supartz FX is safe and effective 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial imaging. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
treadmill testing was not found to be unreliable or inconclusive.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that at issue is the medical appropriateness and necessity of carrying out a radionuclide stress 
test. There is no documentation that the electrocardiogram shows an uninterpretable pattern or that the enrollee 
is unable to exercise. There is no evidence provided that would support the need for radionuclide stress testing 
at this time. There is insufficient documentation to support the medical necessity for the requested cardiac 
stress testing in this enrollees clinical management. 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve myocardial imaging.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines. 
The Plan says that the services needed may be provided safely in 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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 as 
the enrollee currently meets full IRF criteria. You say the skilled nursing facility will not take the enrollee 
because they have tested positive for COVID-19. The Plan denied your request. The Plan says the enrollee does 
not meet the indications for coverage of 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 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.