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

 
We decided that the Plan does not have to pre-approve Entyvio every 6 weeks. 
 
You asked the Plan to pre-approve Entyvio every 6 weeks. You say that the enrollee has been on Entyvio since 
2019. The Plan denied your request. The Plan says the requested dosing is not medically necessary. 
 
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 Entyvio every 6 weeks. Our reviewer 
says that the requested frequency of every 6 weeks is not medically necessary. Our physician reviewer found 
the medical records provided and the Medicare-approved major drug compendia there is no documentation that 
the Entyvio every 6 weeks meets Medicare criteria for medically reasonable and necessary for the patient. The 
only maintenance dosing schedule for Entyvio for the enrollee's condition that is approved and supported in the 
compendia is every 8 weeks. 
 
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 every 6 weeks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Entyvio every 6 weeks.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve Humira. You say that you believe it is in the best interest of the enrollee to 
continue with her current regimen of Humira. The Plan denied your request. The Plan says Humira is on the 
self-administered drug list and is excluded from coverage under Part B. 
 
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 Humira.  
 Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt system (E1002) and related hardware 
(E1028, E0955, E2311). 
 
You asked the Plan to pre-approve a power tilt system and related hardware. You say that the enrollee needs 
these items. The Plan denied your request. The Plan says these items are not necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a power seating system is covered if the beneficiary is 
at high risk for development of a pressure ulcer and is unable to perform a functional weight shift, the 
beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer 
from the wheelchair to bed, or the power seating system is needed to manage increased tone or spasticity. 
 
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 power tilt system and related 
hardware. Our reviewer says that the requested items are not medically necessary. Our physician reviewer 
found the documentation does not clearly support that this patient is unable to perform a functional weight 
shift. The patient can walk and few steps and transfer independently. The patient does not utilize intermittent 
catheterization. There is no evidence of increased tone or spasticity. 
 
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 power tilt system and related hardware have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power tilt system (E1002) and related hardware (E1028, 
E0955, E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (81455) provided on June 3, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed with the appropriate 
POS code. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the genetic testing (81455) provided on June 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says you do not require daily skilled nursing services such as the administration 
of IV antibiotics, management and education of a new PEG tube or colostomy, or complex 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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that based on the medical 
records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide 
medically necessary and reasonable treatment.  The medical records do not document the need for intravenous 
medications, new tube feeding, or ostomy care or daily complex wound care. You do require skilled therapy 
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and 
effectively provide medically necessary and reasonable treatment. There is no documentation that daily skilled 
services are required. You are walking household distances with a rolling walker with supervision, and you are 
at a minimum assist for transfers. The provided records do not document a significant decline in your 
functional status to necessitate daily inpatient skilled therapy services. As a practical matter, there is no 
documentation that you require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in the home with home health care or in a long-term care facility on a part time basis appear 
appropriate in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens (V2781), and frames (V2020), provided 
on December 3, 2021. 
 
You asked the Plan to pay for the eyewear. You say that the items should be covered. The Plan denied your 
request. The Plan says you obtained these items through an out-of-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 obtained through a network provider. 
 
We looked at the file and the Plan's rules. You obtained the eyewear from an out-of-network provider. Based 
on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, 
we decided that the Plan does not have to pay for the progressive lens (V2781), and frames (V2020), provided 
on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit (99214) provided on 
October 24, 2021. 
 
You asked the Plan to reduce the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $10 for 
each covered office visit to your primary care provider for urgently needed services and $40 for each covered 
office visit to other providers for urgently needed services. 
 You have been asked to pay a $40 copayment for the office visit provided at an urgent care facility. This 
service was rendered by a provider other than your primary care physician. 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 reduce the copayment for the office visit (99214) provided on October 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance services (A0429) provided on 
November 2, 2021. 
 
You asked the Plan to pay for the emergency ambulance services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the provider is billing claim with 
CPT code and modifier that is not reimbursable according to CMS billing guidelines. 
 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 A0429 is ambulance service, basic life support, 
emergency transport (bls-emergency). 
 
We find that CPT code A0429 is not supported in the medical record. Specifically, this claim was billed with 
the QL modifier to indicate that the enrollee was pronounced dead after the ambulance was called but before 
the ambulance arrived at the scene. It is not appropriate to bill CPT code A0429 with the QL modifier. Based 
on this information, we decided that Medicare rules for coverage of the emergency ambulance services have 
not been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance services 
(A0429) provided on November 2, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a urology specialist office visit provided on 
September 23, 2021. 
 
You asked the Plan to waive the copayment for a urology specialist office visit. You say that you say that you 
only dropped off a urine sample, then had an appointment four days later. You also say that you have dropped 
off a sample like this before and were never charged for a visit. The Plan denied your request. The Plan says 
that you have been charged the correct cost sharing amount. 
 
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 Plan did not provide medical records to show what services were provided. 
Without the medical records we are unable to determine if cost sharing applies. Therefore, we decided that the 
Plan has to waive the copayment for a urology specialist office visit provided on September 23, 2021.  
 
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 Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the criteria have not 
been met and it has not been demonstrated that it is medically necessary to make an exception for the enrollee. 
 
  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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial 
of (1) an oral bisphosphonate drug (e.g., Alendronate, Ibandronate, Risedronate) and (2) Zoledronic Acid 
(generic Reclast). Our reviewer found that in this case, the patient has not tried and failed the required drugs. 
Our physician reviewer also found that there is no documentation provided indicating that the Plans required 
drugs 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF is the only facility type that can accept you 
with your breathing machine. The Plan denied your request. The Plan says IRF care is not medically necessary 
and you can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for respiratory failure and chronic obstructive pulmonary disease exacerbation. Your medical 
problems are stable and you have no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is needed because you just had surgery and 
need physical therapy for mobility. The Plan denied your request. The Plan says your care needs can be met at 
a lower level of care. 
 
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 IRF 
care is not medically necessary. Our physician reviewer found the complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for osteomyelitis of the toe with amputation of the toe, urinary tract 
infection, and acute on chronic renal disease. Your medical problems are stable and you have no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve dermatology services. You say that it is medically necessary for these 
services to be provided by an OON provider. The Plan denied your request. The Plan says there are multiple in-
network options that can provide the medical care you require. 
 
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 
dermatology services 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 Androgel gel 1.62%. 
 
You asked the Plan to pre-approve Androgel gel 1.62%. You say that the enrollee has tried the cheaper 
alternative monthly injection and was never able to get his testosterone in the target range. The Plan denied 
your request. The Plan says Androgel is a self-administered drug and does not fall under Part B coverage. 
 
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 Androgel gel 1.62%.  
 
Benefits for Androgel gel 1.62% 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 a radiofrequency ablation procedure (64635). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this procedure is considered investigational 
and is non-covered. 
 
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 radiofrequency ablation procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the clinical value and effectiveness of radiofrequency ablation to the 
sacrococcygeal region in the setting of chronic pain has not been demonstrated in the peer-reviewed literature. 
 
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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that only when no significant improvement has occurred 
in the most recent four weeks may the lymphedema be considered unresponsive to conservative therapy, and 
coverage for a Pneumatic Compression Device considered. 
 
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 pneumatic compression device. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has lymphedema and a non healing diabetic foot ulcer. The record does not indicate 
what conservative management techniques that the enrollee has tried and failed. The record does not indicate 
that the enrollee has failed a four week conservative therapy trial. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0651).