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

 
We decided that the Plan does not have to pre-approve a Volara system. 
 
You asked the Plan to pre-approve a Volara system. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 a Volara system. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Volara device is not medically necessary. The Volara device has 3 components: Airway 
oscillation, positive end expiratory pressure, and nebulization. The device has not been studied enough to show 
benefit in the treatment of any chronic lung disease. There is inadequate evidence that this device is as, or more, effective than other devices in achieving airways clearance. 
 
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 Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 
You asked the Plan to pre-approve the ILR placement. You say that it is felt that this is needed and that the 
results will have a direct impact on treatment.  The Plan denied your request. The Plan says there is no 
evidence of syncope that would require this long-term monitoring. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR may be placed when the enrollee has syncope 
that may be cardiac-related but is too infrequent for other testing methods.  
 
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 ILR placement. Our reviewer says 
that the requested ILR is not shown to be reasonable and necessary based on NCD guidelines. Our physician 
reviewer found the enrollee is a female with a history of atrial fibrillation. There is no documentation provided 
to suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for an ILR. 
There is insufficient documentation to support the medical need for the ILR in this enrollee's 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 ILR placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and the 
administration of the drug provided on February 01, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs and the administration of the drug. You 
say that you are unable to afford the cost share applied. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy drugs and the administration of the drug. This 
item/service falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total you owe is $915.97, which is 20% of the 
allowed amount for chemotherapy drugs and the administration services. Therefore, we decided that the Plan 
does not have to waive the coinsurance for chemotherapy drugs and the administration of the drug provided on 
February 01, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation mileage. 
 
You asked the Plan to provide additional mileage. You say that you need to see this doctor at this location for 
important medical treatment. The Plan denied your request. The Plan says the requested location is a greater 
driving distance than is covered by your transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation trips that do not exceed 50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the requested 
destination is more than 50 miles of driving distance from your home. Therefore, we decided that the Plan does 
not have to provide additional routine transportation mileage.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips. 
 
You asked the Plan to provide additional transportation. You say that you need this transportation to get to and 
from your necessary medical appointments and cannot depend on other alternative means of transportation. The 
Plan denied your request. The Plan says trips beyond the 24 one-way trips provided each year are not a covered 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request for additional trips exceeds the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 25, 2021, 
to October 9, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
provided supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. The 
Plan says the diagnosis codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 - sepsis, unspecified organism) and I21.4 - 
Non-ST elevation myocardial infarction. 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 
inpatient hospital services at the DRG originally billed. Our physician reviewer found the enrollee presented 
with leukocytosis, cholecystitis and antibiotics were initiated. However, the enrollee had no significant 
hypotension, requiring for vasopressor support on admission and during the hospital stay. The enrollee had no 
significant mentation change on admission and during the hospital stay that was attributed to sepsis. There was 
no significant hypoxia being attributed to sepsis. The serum creatinine levels, and platelet levels were normal. 
The review has determined that the documentation did not support diagnosis code A41.9. The records more 
support DRG 418.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 25, 2021, to October 9, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the left greater and lesser occipital nerve radiofrequency ablation 
(64633). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the left greater and lesser occipital nerve radiofrequency ablation is not 
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 the service. Our physician reviewer 
found RFA of the occipital nerves is a long-established method of therapy. The request is deemed 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 service have been met. Therefore, we decided that the Plan has to pre-
approve the left greater and lesser occipital nerve radiofrequency ablation (64633).  
 
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 an electronic foot and electronic knee features for a 
prosthetic leg (L5828, L5830, L5845, L5848, L5856, L5973). 
 You asked the Plan to pre-approve the items. You say that the requested items are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested items are not 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 the items. Our physician reviewer 
found the need for the specific technological features of the knee and foot are not provided in the prosthetist's 
notes, nor the physician notes. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electronic foot and electronic knee features for a prosthetic leg (L5828, L5830, L5845, 
L5848, L5856, L5973).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TissueCypher Barrett's Esophagus test (0108U) 
provided on November 10, 2022. 
 
You asked the Plan to pre-approve the testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says TissueCypher Barrett's Esophagus test remains unproven for determining 
the risk of progression from Barrett's esophagus to high grade dysplasia or cancer.  
 
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 testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided medical records and review of the current peer-reviewed medical literature do not 
support that use of the TissueCypher Barrett's Esophagus test has been shown in controlled studies in a Centers 
for Medicare & Medicaid Services (CMS)-approved journal to result in long term health benefits in patients 
with Barrett's esophagus. Although records from the test manufacturer/vendor argue medical necessity of the 
requested test, records from the enrollee's actual treating provider do not clarify why the requested test is the 
most appropriate evaluation for the enrollee's condition. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the TissueCypher Barrett's Esophagus test (0108U) provided on November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed with a low-air mattress to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a semi-electric hospital bed with a low-air mattress to be provided by an 
OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. 
The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan 
says there are in-network providers available to the enrollee that can provide the items being requested. 
 
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 semi-electric hospital bed with a low-air mattress to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve the medication. You say that you would like the Plan to reconsider their 
denial. 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 Mounjaro.  
 
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 the Retacrit (Q5106). 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is necessary for the 
enrollee's treatment.  The Plan denied your request. The Plan says the requested use of this drug is not approved 
by the FDA for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our physician reviewer 
found the requested use of Retacrit is not FDA-approved for the enrollees diagnosis. The use is not supported 
by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal; not with a hemoglobin greater than 10 and evidence of resolving 
iron deficiency. 
 
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 the Retacrit (Q5106).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285, C1764). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested ILR is not medically necessary given the NCD and internal 
criteria.  
 
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 physician reviewer 
found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or 
any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in this enrollee's 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (33285, C1764).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Durable Medical Equipment (DME) 
supplies (E1399) or pay for the sales tax (S9999) provided on November 3, 2022. 
 
You asked the Plan to waive the coinsurance for the DME supplies and to pay for the sales tax. You say that 
you would like the Plan to reconsider reimbursing you in full for the crutches, which you believe will most 
definitely eliminate many other future medical problems. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. The Plan also says that Medicare does not reimburse separately for sales tax. 
 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies. The rules also say that Medicare does 
not make separate payment for sales tax. 
 
You have been asked to pay a 20% coinsurance for the DME supplies. This item/service falls within the 
Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for the Durable Medical Equipment (DME) supplies (E1399) or pay for the sales tax (S9999) 
provided on November 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are just getting over pneumonia, admission is 
medically necessary. The Plan denied your request. The Plan says you have no defined skilled nursing needs 
for wound care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 there are no services offered at a SNF that are not offered at an inpatient rehab 
facility. Admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.