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

 
We decided that the Plan does not have to pre-approve Xeomin. 
 
You asked the Plan to pre-approve Xeomin. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Xeomin is only covered for certain 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 Xeomin. Our reviewer says that the 
documentation does not support that Xeomin is medically reasonable or necessary. Our physician reviewer 
found the enrollee has oromandibular dystonia, helped by Botox. A request was made for botulinum toxin 
(Xeomin). Although this condition is an off-label indication for Botox, this is not so with the Xeomin product 
at this time. Current evidence available does not sufficiently support this use of Xeomin for this condition. 
Therefore, due to the lack of high-quality supportive evidence for this off-label indication, the Xeomin will be 
considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xeomin have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Xeomin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards and push handles for a manual wheelchair. 
 
You asked the Plan to pre-approve side guards and push handles. You say that the requested items are a 
necessity for your care. The Plan denied your request. The Plan says rules for coverage of durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve side guards and push handles for a manual wheelchair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ultrasound provided on August 10, 
2023, to September 08, 2023. 
 
You asked the Plan to waive the copayment for each ultrasound. You say that you are requesting 
reconsideration of the copayments applied to the claim. 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 a $85 
copayment for outpatient radiological diagnostic services, including an ultrasound. 
 
You have been asked to pay a $85 copayment for each ultrasound. This item/service falls within the outpatient 
radiological diagnostic services, including an ultrasound 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 copayment for each ultrasound provided on August 10, 2023, to September 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implantable programmable neurostimulator pulse 
generator provided on July 21, 2023. 
 
You asked the Plan to pay for the implantable programmable neurostimulator pulse generator. You say that you 
are requesting reconsideration of the denied claim. 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 the implantable 
programmable neurostimulator pulse generator provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the preventive exam, coded 99397, billed for date of service June 6, 
2023. 
 
You asked the Plan to pay for the services provided. You say that you should not owe anything for the services. 
The Plan denied your request. The Plan says that the preventive medicine service is non-covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The services at issue were provided by a contract provider. The file does not show that the Plan provided notice 
that the services provided. would not be covered. Under Medicare rules, this means the services provided. is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the preventive exam, coded 
99397, billed for date of service June 6, 2023.  
 
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: Favorable

 
We decided that the Plan has to pre-approve the K3 microprocessor knee (L5828, L5845, L5848, L5856). 
 
You asked the Plan to pre-approve the K3 microprocessor knee. You say that the items are medically 
necessary. The Plan denied your request. The Plan says that the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 K3 microprocessor knee. Our 
reviewer says that the items are not medically necessary. Our physician reviewer found the providing physician 
documentation indicates enrollees current functional level exceeds current prosthetic foot and knee 
components and componentry is holding enrollees progression and is a safety concern. 
 
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 K3 microprocessor knee have been met. Therefore, we decided that the Plan 
has to pre-approve the K3 microprocessor knee (L5828, L5845, L5848, L5856).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service May 16, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says the testing is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
The file shows that a DecsionDx-SCC test was provided. We looked at the file and Medicare rules. The 
medical records do not document how the test results will impact the treatment/management of the enrollees 
specific medical problem. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service 
May 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic (semaglutide). 
 
You asked the Plan to pre-approve the medication. You say that the weight loss that may happen with this 
medication would also help lower the blood pressure again, helping slow the progression of kidney failure. 
Youi also say this would help with diabetes. 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 Ozempic (semaglutide).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immersion therapy mattress (E1399). 
 
You asked the Plan to pre-approve an immersion therapy mattress. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says there is no Medicare coverage for a 
mattress that is not an air fluidized bed. 
 
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 immersion therapy mattress. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have multiple sclerosis and healing ulcers. Per L33692, the plan has 
approved a group 3 bed. An immersion bed is not medically necessary for you. 
 
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 immersion therapy mattress have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an immersion therapy mattress (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service September 5, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the test was medically necessary. The Plan denied 
your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 The file shows that the provided urinary tract infection panel test was billed using codes 87481, 87500, 87640, 
87652, 87798, 87799, and 87900. We looked at the file and Medicare rules. The documentation supports that 
this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple 
methodologies, or multiple kits were used in this case. As such, a single code with one unit of service should be 
used. Based on this information, we decided that Medicare rules for coverage of the testing panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the panel testing billed for date of service 
September 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthosis provided on August 17, 2023. 
 
You asked the Plan to pay for the ankle orthosis. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim line is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines billed with codes without a KX, GA 
or GZ modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. Review of the file shows that code L1902 was only billed with 
modifier RT. The claim was not billed with a required modifier. Based on this information, we decided that 
Medicare rules for coverage of the ankle orthosis have not been met. Therefore, we decided that the Plan does 
not have to pay for the ankle orthosis provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive electrophysiologic evaluation with 
catheter destruction of abnormality causing atrial fibrillation, and ultrasound of heart with probe in esophagus. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation shows that the enrollee was seen by the electrophysiologist in 12/2023, with the 
plan to carry out transesophageal echocardiography followed by electrical cardioversion. There is no record of 
consideration or discussion of electrophysiologic study and catheter ablation of atrial fibrillation. At the current time, based on the records provided, catheter ablation of atrial fibrillation would not be considered to be 
medically necessary in this 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve comprehensive electrophysiologic evaluation with catheter destruction of abnormality 
causing atrial fibrillation, and ultrasound of heart with probe in esophagus.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on August 28, 2023. 
 
You asked the Plan to pay for the home health services. You say that the assisted living facility is responsible 
to obtain prior authorization for all of their patients. 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 the home health services 
provided on August 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation due to needing continued medical oversight and intensive therapy services. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, but skilled therapies as an outpatient or at 
a skilled nursing facility (SNF) may be approved upon request.  
 
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 based on the medical records provided 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. The enrollee's medical conditions appear stable on outpatient medications with 
no issues that appear to require a physician's evaluation three or more times per week in a hospital setting. The 
enrollee does require physical therapy and occupational therapy services, but the medical records provided do 
not clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. Provided medical 
records do not support that the intensive inpatient rehabilitation therapy program is necessary and that therapy 
at a lower level of care such as in a skilled nursing facility (SNF) is not appropriate for the enrollee. Based on 
the medical records provided the enrollee would be expected to participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility, however the medical records do 
not support a complexity of needs to require an acute inpatient rehabilitation facility with an interdisciplinary 
team over a skilled nursing facility.  
 
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 based on the enrollee's current condition and 
functional deficits, as well as their comorbidities, the enrollee meets full inpatient acute rehabilitation criteria. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies 
as an outpatient or at a skilled nursing facility (SNF) may be approved upon request.  
 
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. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. 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. 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: 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 to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria.  
 
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. The enrollee 
was admitted for respiratory failure, COVID 19 infection, pneumonia, atrial fibrillation. Clostridium difficile 
infection and hyponatremia. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. 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. There is not a reasonable 
expectation that this 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.