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 a glucose test provided on May 23, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit and glucose test provided OON. You say that you weren't aware 
that the doctor or group was OON with the enrollee's specific plan. You say that the documentation provided 
supports that the services in dispute were medically necessary. The Plan denied your request. The Plan says the 
OON services were not authorized. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and a glucose test provided on May 
23, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilaris. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Ilaris is indicated by the Food and Drug 
Administration (FDA) for treatment of Familial Mediterranean Fever (FMF) in adult and pediatric patients and 
active Systemic Juvenile Idiopathic Arthritis (SJIA) in patients aged two years and older. The enrollee has a 
diagnosis of hidradenitis suppurativa. Ilaris is not approved by the FDA for this diagnosis. Its use is not 
supported by one of the major drug compendia or clinical research appearing in a Medicare-approved medical journal. 
 
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 pre-approve Ilaris.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic recording (93228, 93229). 
 
You asked the Plan to pre-approve mobile cardiac outpatient telemetry. You say that you are requesting 
reconsideration and have submitted cardio and physician notes for review. The Plan denied your request. The 
Plan says the records do not show documentation that the enrollee is having any symptomatic arrythmias, that 
he has had an ablation or that it is needed to adjust the regulation of an antiarrhythmic drug dosage for him. 
 
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 mobile cardiac outpatient telemetry. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in the absence of palpitation, syncope, or history of significant 
symptomatic arrhythmia, using a mobile cardiac event monitor is not a medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mobile cardiac outpatient telemetry have not been met. Therefore, we decided 
that the Plan does not have to pre-approve external mobile cardiovascular telemetry with electrocardiographic 
recording (93228, 93229).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Skyrizi. 
 
You asked the Plan to pre-approve Skyrizi. You say that Skyrizi is a medical necessity for the enrollee. 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 drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Skyrizi.   
Benefits for Skyrizi 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 in-home ventilator (E0466). 
 
You asked the Plan to pre-approve an in-home ventilator. You say that this is medically necessary for the 
enrollee. You also say that without non-invasive ventilator (NIV) therapy, the enrollee is at high risk for 
hospital readmission and potentially life-threatening exacerbations. The Plan denied your request. The Plan 
says a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. The Plan also 
says that this device may be obtained from a network provider. 
 
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 an in-home ventilator. Our reviewer 
says that the requested in-home ventilator is not medically necessary. Our physician reviewer found the 
provided documentation indicates the enrollee was recently admitted for chronic obstructive pulmonary disease 
(COPD) exacerbation and found to have pneumonia. The enrollee responded well with bi-level positive airway 
pressure (BIPAP) therapy and should continue BIPAP with or without average volume-assured pressure 
support (AVAPS). The enrollee has multiple comorbidities to explain their multiple hospitalizations and 
although they have COPD and previous tracheostomy, the initiation of home ventilator is not documented in 
medical records provided. Therefore, the reviewer found that the requested in-home ventilator is not medically 
reasonable or 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 an in-home ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an in-home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage have not been met.  
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 ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no concordant radiological image-based diagnostic testing supporting lumbar 
radiculopathy, radicular pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte 
complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis, or post-
laminectomy syndrome. Therefore, the criteria for coverage have not been 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 the ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ESI.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
February 19, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this is 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 pay for the panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a 
urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large 
multiplex PCR urinary tract infection panel tests. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine polymerase chain reaction (PCR) panel provided on February 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 documentation 
does not specify any acute clinical concern, change of plan of care or in medication regimen. The records do 
not show that additional home health skilled nursing visits are required to effectively provide treatment, care, 
and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. The enrollee's concerns listed include functional 
impairments and weakness (of legs) as opposed to medical concerns. 
 
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 skilled nursing.
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 is unable to maintain weight-bearing 
restrictions in his home environment presenting a risk of further injury. The Plan denied your request. The Plan 
says the enrollee does not meet the requirements for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do not require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support the need for an IRF admission. The enrollee can receive further services 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 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 IRF care is necessary to regain functional strength 
and mobility. The Plan denied your request. The Plan says IRF care is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in 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 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 a water circulating heat pad with pump (E0217) provided 
from February 28, 2023, to March 23, 2023. 
 
You asked the Plan to pay for a water circulating heat pad with pump (E0217) . You say that this item was 
medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that water circulating heat pads with pump (E0217) are 
excluded from coverage.  That means that regardless of medical necessity, this item cannot be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump (E0217) have not been met. Therefore, we decided that the 
Plan does not have to pay for a water circulating heat pad with pump (E0217) provided from February 28, 
2023, to March 23, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia. 
 You asked the Plan to pre-approve treatment with Prolia. You say that Prolia is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of Prolia 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 treatment with Prolia. Our reviewer 
says that treatment with Prolia is not medically reasonable and necessary in this case. Our physician reviewer 
found that the Plan requires a trial of oral bisphosphonates before they will approve the requested drug. The 
requested drug is a new start. The provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment with Prolia have not been met. Therefore, we decided that the Plan 
does not have to pre-approve treatment with Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrest) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee is not able to shift their weight or perform pressure relief. You say that the power tilt and recline will 
allow the enrollee to significantly reduce the number of transfers performed daily. You also say that this is 
necessary to allow the enrollee to live safely at home. The Plan denied your request. The Plan says the enrollee 
does not have a medical need for multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the documentation does not support 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. The reviewer found that 
the enrollee has no history of prior pressure ulcer with prior wheelchair use and no documentation of flap 
surgery. Therefore, the reviewer found that the requested Group 3 power wheelchair with multiple power 
options is not medically reasonable or 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 Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, legrest) and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an initial hospital inpatient or observation care (procedure 
99223) provided on March 2, 2022. 
 
You asked the Plan to pay for an initial hospital inpatient or observation care (procedure 99223). You say that 
procedure code 99223 is appropriate based on the level of services required. The Plan denied your request. The 
Plan says procedure code 99223 is not supported by the documentation submitted.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
 
  We asked our coder 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 an initial hospital inpatient or observation care (procedure 
99223). Our reviewer says that the records do not support the services at issue in this case. Our reviewer found 
that the documentation describes the enrollee as presenting with chronic neuropathy in extremities and 
shortness of breath but no weakness of the extremities. A computed tomography (CT) head scan showed 
concern for right frontal lobe infarction. The enrollee was alert and oriented with relatively stable vitals. The 
enrollee was diagnosed with large pleural effusions, deep vein thrombosis (DVT), and new onset atrial 
fibrillation. The enrollee was started on oxygen support, Lovenox, planned for a magnetic resonance imaging 
(MRI) of the brain, thoracentesis the next day, and other workup. Although the documentation supported an 
appropriate history and exam, it does not support a high level of decision making or a duration of the encounter 
being 75+ minutes as required to justify the code, 99223. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an initial hospital inpatient or observation care (procedure 99223) have not been 
met. Therefore, we decided that the Plan does not have to pay for an initial hospital inpatient or observation 
care (procedure 99223) provided on March 2, 2022.