Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve monthly Xgeva injections. 
 
You asked the Plan to pre-approve the Xgeva. You say that this medication should be continued to treat the 
enrollee's condition. The Plan denied your request. The Plan says that the enrollee had not started Xgeva and 
there has been no trial of zoledronic acid as required by step therapy. 
 
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. However, step therapy may only be applied to new prescriptions or administrations of Part 
B drugs for enrollees that are not actively receiving the affected medication. 
 
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 Xgeva. Our reviewer says that the 
documentation supports that Xgeva is medically reasonable and necessary and that it was initiated prior to the 
step therapy denial. Our physician reviewer found the enrollee has a diagnosis of age-related osteoporosis as 
well as metastatic cancer to the bone and brain. Although there is a report from office staff that Xgeva had not 
been received, there are at least two references supporting that Xgeva was initiated in the signed medical 
records.  
 
A follow-up neuro-oncology telemedicine visit on 11/25/20 documents that current treatment included "Cycle 1 
palbociclib/tamoxifen with denosumab." The Oncologic Treatment History documents that 
palbociclib/tamoxifen with denosumab was initiated on October 20, 2020. As such, denial on the basis of step 
therapy is not appropriate. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. It is documented in several places that this is 
a continuation of previously initiated therapy. Medicare rules dictate that progress note that has been signed 
and dated by a physician is the highest level of evidence. We find that a phone call with a member of the office 
staff is not sufficient to override what is documented in the records. As such, based on the available 
information, we decided that Medicare rules for coverage of the Xgeva have been met. Therefore, we decided 
that the Plan has to pre-approve monthly Xgeva injections.  
 
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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 documentation does support that the enrollee requires skilled nursing and skilled therapy services in the SNF setting. Our physician reviewer found the enrollee received oral and inhaled medications. The enrollee had stable vital signs. The enrollee required minimal to moderate assistance with functional mobility. The enrollee required varying assistance with activities of daily living. The documentation does support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does require the necessary services on an inpatient basis, at a SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (J7318) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the step therapy guidelines. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed one viscosupplemental treatment such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires that one of these be trialed first. The documentation does not outline contraindications or reasons these 
 
 
medications were not considered. Without the support of the documentation, Durolane is not approved as step 
criteria 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane (J7318) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that Entyvio is medically necessary. The Plan denied your 
request. The Plan says a trial of Remicade OR Inflectra AND Stelar is required before alternative drugs can be 
considered. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically necessary. Our physician reviewer found the records do not show a failed trial of the 
plan's preferred drugs, or any reason why the plan preferred drugs would be unsafe or ineffective 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided on August 4, 2020. 
 
You asked the Plan to waive the deductible for the office visit. You say that you weren't informed that the 
clinic was not in-network. You say that you cannot afford this cost every time you see your doctor. The Plan 
denied your request. The Plan says the deductible applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost for most of your covered services. Out-of-network services are not excluded from 
the deductible. 
  
The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner 
services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $750 deductible applies to out-of-network services. This cost sharing is a 
contractual obligation that had not been met at the time the office visit was received on August 4, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on 
August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction services (92015) provided June 26, 2020. 
 
You asked the Plan to pay for the vision services. You say that you are appealing for the plan to pay for this 
refraction exam. You did not know that it wasn't covered or that this doctor was not in the system. The Plan 
denied your request. The Plan says enrollee's must receive their vision services from an in-network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when rendered by a participating provider and when performed as part 
of a routine screening. 
 
 
 
 
 
We looked at the file and the Plan's rules. Eye refraction services are only covered when rendered by a 
participating provider and when performed as part of a routine screening. Based on this information, we 
decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that 
the Plan does not have to pay for the eye refraction services (92015) provided June 26, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
1, 2020 to May 28, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration because this 
service was billed correctly. The Plan denied your request. The Plan says the claim must be billed with a TOB 
code of 0329. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was submitted with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay for 
the home health services provided to the enrollee from May 1, 2020 to May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital clinic services provided May 19, 
2020. 
 
You asked the Plan to pay for the hospital clinic services. You say that the claim has not been paid in full or 
under the terms of the contract for the services provided. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the outpatient hospital clinic services provided May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Mobile Cardiac Outpatient Telemetry (93229). 
 
You asked the Plan to pre-approve the mobile telemetry. You say that the medical device is necessary. The 
Plan denied your request. The Plan says that the enrollee did not meet these criteria because they could use a 
standard heart monitor. 
 
The Plan follows Medicare rules. Medicare rules say that Real-time outpatient cardiac telemetry is considered 
medically unnecessary if it is unlikely to provide clinical data or information beyond that which has already 
been obtained from a previous test.  
 
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 mobile telemetry.  
 
 
Our reviewer says that you need this medical item. Our physician reviewer found the enrollee is having 
significant cardiac rhythm disturbances. It is indicated to do longer monitoring than can be obtained from a 
standard Holter Monitor before deciding whether to pursue permanent pacemaker. 
 
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 mobile telemetry have been met. Therefore, we decided that the Plan has to 
pre-approve Mobile Cardiac Outpatient Telemetry (93229).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional paravertebral facet joint nerve destruction and 
additional moderate sedation provided on February 25, 2020. 
 
You asked the Plan to pay for additional paravertebral facet joint nerve destruction (64636) and additional 
moderate sedation (99153). You say that the Plan should pay this claim The Plan denied your request. The Plan 
says the procedures are not supported in the medical records. 
 
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 64636 is Destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 
(List separately in addition to code for primary procedure). The CPT Code Manual definition of code 99153 is 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service).    
 
We find that CPT code 64636, 99153 is not supported in the medical record. Specifically, the amount of units 
for destruction of the nerve is not documented. There is no documentation of intraoperative conscious sedation 
start and stop time. Based on this information, we decided that Medicare rules for coverage of additional 
paravertebral facet joint nerve destruction (64636) and additional moderate sedation (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for additional paravertebral facet joint nerve 
destruction and additional moderate sedation provided on February 25, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs more time to fully recover. 
The Plan denied your request. The Plan says the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on 
November 17, 2020. The physical therapy note dated December 7, 2020 states she needs modified assistance 
with transfers and bed mobility. She needs total assistance with walking 10 feet. She has no documented skilled 
nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a 
practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the surgical procedure provided on April 28, 2020. 
 
You asked the Plan to pay for the surgical procedure. You say that the surgical procedure was medically 
reasonable and necessary. The Plan denied your request. The Plan says that the surgical procedure was not 
medically reasonable and necessary and was considered to be done for cosmetic reasons. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The case file documents that the surgery was for "removal of table flap that was 
causing the enrollee to fall. He is a 100 percent disabled veteran and had fallen thru a plate glass window due to 
this causing his equilibrium off." However, the Plan has not provided documentation to address this concern. 
The file does not show that the Plan made any attempts to obtain any medical records for this issue from any 
treating physicians the enrollee may have been seeing. We find that the Plan has not proven that the surgery 
was not performed due to a medical necessity need. Therefore, we decided that the Plan has to pay for the 
surgical procedure provided on April 28, 2020.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee x-ray provided on August 25, 
2020. 
 
You asked the Plan to waive the copayment for the knee x-ray. You say that follow up x-rays should be 
covered in full under the global period post-surgery benefit. The Plan denied your request. The Plan says the 
copayment applied 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 $55 
copayment for each Medicare-covered standard x-ray and ultrasound.  
 
You have been asked to pay $37.87, which is less than the standard $55 copayment for the knee x-ray. The 
knee x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 
There is no provision in the contract which indicates a copayment would be waived for a service performed as 
a follow-up to a surgical procedure. 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 the knee x-ray 
provided on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthetic leg as a replacement (a new socket and 
a prosthesis including a K3 foot and ankle). 
 
You asked the Plan to pre-approve a new prosthetic leg. You say that you would like the plan to reconsider 
their denial The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that replacement prosthetic legs are 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 a new prosthetic leg. Our reviewer says 
that the documentation does not support that the requested new prosthetic leg is medically reasonable or 
necessary. Our physician reviewer found the enrollee's current prosthesis is over 3 years old the socket no 
longer fitting well due to weight gain. The requested new prosthetic leg as a replacement (a new socket and a 
prosthesis (K3 foot and ankle)) is not medically necessary. The medical progress reports and documentation do 
not support that the enrollee has vocational, therapeutic, or exercise activity or goals that demands prosthetic 
utilization beyond simple locomotion. The enrollee's goals are to walk around her yard and walk around the 
mall independently or with a cane which is not consisted with K3 level ambulation. The enrollee currently has 
blurry vision (which requires surgery), multiple comorbidities, current primary use of a wheelchair for 
ambulation do not support a prosthesis beyond a K2 level. Therefore, the enrollee does not meet criteria for the 
requested item. 
 
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 new prosthetic leg have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a new prosthetic leg as a replacement (a new socket and a prosthesis including a 
K3 foot and ankle).