Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ferumoxytol injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs Infed (iron dextran) 
and Venofer (iron sucrose). 
 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 injection. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has iron deficiency anemia. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. 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 alternative. The elements of the coverage criteria are not satisfied. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ferumoxytol injection for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on October 22, 2021. 
 
You asked the Plan to pay for paramedic intercept services. You say that this bill should be covered by the 
Plan. The Plan denied your request. The Plan says these services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances.  Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a 
qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer 
ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the 
transport or BLS services.  
 
The Plan has confirmed that the provider does not have a contract with the volunteer ambulance company that 
provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on October 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia 200MG Kit x2 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 they do not have a record from the enrollee's prescriber that shows they have tried one of 
the preferred drugs (Humira, Enbrel or Xeljanz) and it has not worked, or that the enrollee has medical reasons 
that prevent the enrollee from using one of them. 
 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 record indicates that 
the enrollee has arthropathic psoriasis. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. 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 alternative. The elements of the coverage criteria are not satisfied. 
 
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 Cimzia 200MG Kit x2 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing 
facility. 
 
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 upon a review of the available records, you do not meet the coverage criteria for 
admission. You are medically stable, and do not need close physician supervision three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. 
There are no rehab nursing needs identified in the record. At the current functional level with continued fatigue, 
you are more appropriate for skilled nursing facility rehabilitation. There is no need for intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy in an IRF. This admission is not medically necessary, based on medical stability and lack of 
medical complexity. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72040 billed for date of service December 
13, 2021. 
 
You asked the Plan to pay for procedure code 72040. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 72040 is bundled into payment for 
code 72042. 
 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, we have confirmed that code 72040 
is a column II code to column I code 72052. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 72040 billed for date of service December 13, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is considered experimental and unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has chronic Sacroiliitis. She has tried non-steroidal anti-inflammatory drugs 
(NSAIDs) and muscle relaxants. She underwent diagnostic left L5 dorsal ramus, and lateral branches of S1, S2 
and S3, which produced between 80-100% pain relief. The request is for radiofrequency ablation of the lateral 
sacral branches. This is considered experimental/ investigational because of the wide variation in efficacy in 
the peer reviewed literature. Therefore, the request is deemed 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due 
to insufficient evidence of efficacy. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is experimental. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically reasonable and 
necessary. 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 therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Although insulin use was reported, the record that was provided is unclear about the enrollees daily insulin dose. Based on this information, we decided that Medicare rules for coverage 
of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the axolotl graft or axolotl dualgraft (Q4210). 
 
You asked the Plan to pre-approve the axolotl graft or axolotl dualgraft (Q4210). You say that wound #1 and 
#2 are chronic wounds that have not healed. You say that wound #3 is an acute diabetic ulcer and has not 
healed. The Plan denied your request. The Plan says the request is not medically necessary because the records 
show that the wounds are improving with the current wound therapy. 
 
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 axolotl graft or axolotl dualgraft 
(Q4210). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the records sent by the provider indicate the wounds 
are looking much better. The enrollee had a recent procedure to improve the blood flow in both legs and has 
been treated with intravenous antibiotics for infection of the underlying bone on the right great toe. The record 
states that the wounds are now improving with the treatments and the member does not meet the LCD coverage 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the axolotl graft or axolotl dualgraft (Q4210) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the axolotl graft or axolotl dualgraft (Q4210).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ColoGuard testing. 
 
You asked the Plan to pre-approve the ColoGuard testing. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
coverage of this test. 
 
The Plan must follow Medicare rules. Medicare rules say that the COLOGUARDTM test is covered once every 
three years for Medicare beneficiaries that are age 50 to 85 years. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ColoGuard testing have not been met. Specifically, the record shows that you are not between 
50 and 85 years old. Therefore, we decided that the Plan does not have to pre-approve the ColoGuard testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brand specific heavy duty bariatric wheelchair. 
 
You asked the Plan to pre-approve a brand specific heavy duty bariatric wheelchair. You say that a brand 
specific heavy duty bariatric wheelchair is medically necessary inside and outside of the home. The Plan denied 
your request. The Plan says Medicare does not cover brand specific durable medical equipment. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The requested equipment has capabilities not required in the home. The 
Plan is willing to work with your physician to request the appropriate Medicare covered wheelchair for your 
use in the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use 
outside the home. Therefore, we decided that the Plan does not have to pre-approve a brand specific heavy duty 
bariatric wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aspiration or injection into the major joint of the body or 
bursa (20610) Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (J7323). 
 
You asked the Plan to pre-approve the injection services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the medical records do not 
support that the requested service is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the record indicates that the enrollee has a osteoarthritis of the knee. The 
record indicates that the enrollee previously underwent Euflexxa injections. The Food and Drug Administration 
has stated that the requested drug is indicated for the enrollee's condition. The record does not indicate the 
effectiveness of the injections or reflect that the enrollee currently requires retreatment. The record as provided 
is insufficient to establish the medical necessity, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied and the requested service cannot be recommended.  
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 injection services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve aspiration or injection into the major joint of the body or bursa (20610) 
Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with or without Auto-EPAP (AE) that could be delivered by bilateral positive 
airway pressure (BiPAP) is not covered. 
 
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. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you were 
recently hospitalized with mental status changes due to hypoxic and hypercarbic respiratory failure, which was 
resolved with BiPAP. There is a history of obstructive pulmonary disease which is untreated. There is a diagnosis of chronic obstructive pulmonary disease, but there are no pulmonary function tests to confirm. There 
is no documentation of chronic hypercapnic respiratory failure with an arterial blood gas (ABG) done while the 
patient is stable as an outpatient. The enrollee may benefit from BiPAP during sleep, which can provide the 
AVAPS mode of support. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic colonoscopy to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve a diagnostic colonoscopy. The Plan denied your request. The Plan says the 
services are available in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
diagnostic colonoscopy to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital bed rails for the enrollee. 
 
You asked the Plan to pre-approve hospital bed rails. You say that safety hospital bed rails are medically 
necessary for safety. The Plan denied your request. The Plan says safety hospital bed rails are only covered 
when they are included in the rental of a hospital bed. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Hospital grade bed rails are not covered for regular beds. The records do not show the 
enrollee is renting a hospital bed. Therefore, we decided that the Plan does not have to pre-approve hospital bed 
rails for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electric stimulation therapy and manual therapy techniques 
provided from August 25, 2021, through August 30, 2021. 
 
You asked the Plan to pay for electric stimulation therapy and manual therapy techniques. The Plan denied 
your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for electric stimulation therapy and manual therapy techniques provided from 
August 25, 2021, through August 30, 2021.