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

 
We decided that the Plan does not have to pre-approve Ocrevus (ocrelizumab) injections. 
 
You asked the Plan to pre-approve the Ocrevus treatments. You say that the requested drug is medically 
necessary to treat the enrollee's condition. The Plan denied your request. The Plan says a trial of the preferred 
drug is required before Ocrevus can be approved. 
 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 Ocrevus treatments. Our reviewer 
says that the documentation does not support that the requested drug is medically necessary based on the step 
therapy criteria. Our physician reviewer found based on the medical records provided, there is no indication 
that the enrollee has tried and failed the required drug, Kesimpta. There is also no indication that the plan's 
required drug would likely be less effective and/or likely have adverse effects 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 the Ocrevus treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Ocrevus (ocrelizumab) injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cequa. 
 
You asked the Plan to pre-approve Cequa. You say that these eye drops are medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not among those covered under 
the enrollee's medical benefit. 
 
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 Cequa.  
 
Benefits for Cequa 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery fusion. 
 
You asked the Plan to pre-approve spine surgery fusion. 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 spine surgery fusion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not show any evidence of segmental spinal instability, 
fracture, or lesion. Criteria for spine fusion surgery has 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 spine surgery fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spine surgery fusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 7, 2020, to 
January 13, 2020, 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 it is felt 
that this inpatient stay was correctly billed. The Plan denied your request. The Plan says the documentation 
does not indicate that the main reason for this admission was sepsis. As such, this has been billed incorrectly. 
 
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 principal diagnosis code A41.9, defined as sepsis, 
unspecified organism. 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 reviewer says that the documentation does not support the use of 
code A41.9 as the principal diagnosis for this admission. Our physician reviewer found the enrollee was 
admitted to the facility with abdominal pain. She was diagnosed and treated for acute mesenteric ischemia 
secondary to a blood clot near the intestine. She was treated medically, and palliative medicine was consulted. 
She was given intravenous fluids and parenteral antibiotics. The documentation did not support that the 
enrollee's mental status was altered or that she had significant organ dysfunction due to sepsis.  
 
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 January 7, 2020, to January 13, 2020, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care (99221) billed for May 27, 2022. 
 
You asked the Plan to pay for inpatient care. You say that this service was appropriate and was reported 
correctly. The Plan denied your request. The Plan says inpatient care was billed with an inpatient place of 
service code; however, the enrollee's claim history shows that they were outpatient observation status from 
May 27, 2022, to May 28, 2022. This service conflicts with the enrollee's claim history. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that for a service rendered to a patient who is registered inpatient or outpatient of a hospital, the appropriate place of service code is that of 
the associated/appropriate inpatient or outpatient code, regardless of where the face-to-face service occurs.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient care have not been met. Specifically, this service was billed as inpatient care with an 
inpatient POS code, but the records show that the enrollee was outpatient status at the time of care. Therefore, 
we decided that the Plan does not have to pay for inpatient hospital care (99221) billed for May 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service June 17, 
2022. 
 
You asked the Plan to pay for procedure code 76140. You say that this code is appropriate and is supported in 
the medical records. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service June 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services (G0299). 
 
You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of 
approval for home health services due to aftercare following surgery for neoplasm. 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 you reportedly 
had skilled nursing services and skilled therapy for a period of time. The medical records do not address home 
health services. There is no evidence of a physician order, but home health records have not been provided. The 
records are insufficient support of the plan's decision. 
 
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 care services (G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that admission to an 
IRF 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 that you do not have complex or rehabilitation needs. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 (K0862), a power tilt system (E1002), and accessories (E0955, E2621, E1012, E2311, E1028, E1002, 
E2300, E2625, E2377, E2313, K0862, E2363, K0108). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options, a power tilt 
system, and accessories. You say that this is medically necessary. The Plan denied your request. The Plan says 
you do not require multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is covered if the beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and the beneficiary either uses a ventilator which is mounted on the wheelchair 
or meets coverage criteria for a power tilt and recline seating system and the system is being used on the 
wheelchair. 
 
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, a power tilt system, and accessories. Our reviewer says that the records show the 
requested power wheelchair is not medically necessary. Our physician reviewer found the record shows that 
you have normal range of motion in your upper extremities and are independent in transfers. You do not have 
skin breakdown, do not use a catheter, and do not have significant spasm. You do not require a power tilt or 
recline or use a ventilator. 
 
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, a power tilt system, 
and accessories 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 (K0862), a power tilt system (E1002), and accessories (E0955, 
E2621, E1012, E2311, E1028, E1002, E2300, E2625, E2377, E2313, K0862, E2363, K0108).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a complete maxillary denture (D5110). We decided that the Plan 
does not have to pre-approve an unspecified adjunctive procedure (D9999).  You asked the Plan to pre-approve a complete maxillary denture (D5110) and an unspecified adjunctive 
procedure (D9999). You say that you have a lot of pain and cannot eat well. The Plan says that a complete 
maxillary denture (D5110) has already been exhausted. The Plan also says that an unspecified adjunctive 
procedure (D9999) is not covered under this benefit. 
 
We decided that the Plan has to pre-approve a complete maxillary denture (D5110).  
 
Therefore, we decided that the Plan has to pre-approve a complete maxillary denture (D5110). 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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. 
 
We also decided that the Plan does not have to pre-approve an unspecified adjunctive procedure 
(D9999). 
 
 Therefore, we decided that the Plan does not have to pre-approve an unspecified adjunctive procedure 
(D9999). Medicare generally does not cover dental services. However, the Plan offers a dental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. 
 
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 a continuous glucose monitor (CGM) (K0553). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee is having difficulty controlling her blood 
sugars and needs assistance on monitoring to improve her glucose control. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of the requested CGM. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM) (K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sandostatin Lar Depot. 
 
You asked the Plan to pre-approve Sandostatin Lar Depot. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that octreotide acetate for injectable suspension is Food 
and Drug Administration (FDA) approved for the reduction of growth hormone and IGF-1 in patients with 
acromegaly, for whom medical treatment is appropriate, and who have been shown to respond to and can 
tolerate short-acting subcutaneous octreotide acetate. 
 
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 Sandostatin Lar Depot. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the review has determined that 
the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sandostatin Lar Depot have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Sandostatin Lar Depot.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Synvisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has a diagnosis of osteoarthritis of the shoulder. The Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements 
of the coverage criteria are not satisfied. 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 21, 2022, to 
April 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 21, 2022. The NOA was not received by the Plan until December 
21, 2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from March 21, 2022, to April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says admission to an IRF was denied as not meeting criteria, not medically 
necessary, and a lower level of care might be appropriate. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.