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

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of 
respiratory muscle weakness. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in intelligent volume assured pressure support (IVAPS) mode that could be delivered by bilevel 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. This enrollee was recently admitted with dyspnea, 
with new elevation of R hemidiaphragm, possible related to prior cardiac ablation for atrial fibrillation (AF). 
Also, possible pneumonia right lower lobe. Underlying diagnoses of myasthenia gravis and multiple sclerosis. 
Exams indicate no acute respiratory distress, clear breath sounds, good air entry. The forced vital capacity 
(FVC) is 51 to 52% predicted. The PaCO2 is normal. This enrollee does have a generalized neuromuscular 
disease but does not appear to require nocturnal respiratory support at this time, especially as improvement is 
expected. The enrollee does not require continuous ventilator support. Treatment of the obstructive sleep apnea 
(OSA) could be considered. The denial of the ventilator is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that a lower level of care would not offer enough therapy in order for you to make a full recovery and prevent further injuries. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage.
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 you do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided July 3, 2021 to July 7, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you were told that the facility was in-network, otherwise you would not have went there. They are overcharging for services not given. The Plan denied your request. The Plan says the claim was processed with the correct co-insurance applied per the Evidence of Coverage.
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 30% of the total cost for each out of network SNF stay for Skilled nursing facility (SNF) care.
You have been asked to pay $1,2020.10 ($4,007.00 x 30%) for the SNF services. The SNF services falls within the Skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided July 3, 2021 to July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on August 6, 2021.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because the member has chiropractic benefits. The Plan denied your request. The Plan says this service is not covered under any circumstance.
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 the office visit (99213) provided on August 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your 
records do not show that your therapy can only be provided on an inpatient basis and the services you require 
of skilled therapies, can safely be received at a different setting, for example, home with home health, in 
residential care, or home with close follow-up with your doctor. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla for the enrollee.
You asked the Plan to pre-approve Otezla. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Otezla for the enrollee.
Benefits for Otezla may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta (J2506).
You asked the Plan to pre-approve Neulasta. You say that this is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says Neulasta is not being prescribed for a medicallyaccepted
indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Neulasta. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates
that the enrollee has a diagnosis of febrile neutropenia prophylaxis in a patient with acute myeloblastic
leukemia (AML) from pre-existing myelodysplastic syndrome (MDS), a myeloid malignancy. 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 Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta (J2506).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zoledronic acid injection (J3489 and 96365) to be 
rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Zoledronic acid injection. You say that the enrollee has tried Boniva 
which caused gastrointestinal side effects, and Evista which caused a rash. The Plan denied your request. The 
Plan says the requested treating provider is OON. The Plan also says that the service can be safely rendered 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a Zoledronic acid injection (J3489 and 96365) to be rendered by an out-of-network (OON) provider.  Please Note: The Plan has approved the requested drug to be rendered by an in-network provider. Please 
contact the Plan if you have any questions.
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 inpatient rehabilitation services are medically 
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are 
not met. The enrollee's needs can be met in 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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Documentation does not support that the enrollee requires treatment by multiple therapies, 
including either physical therapy or occupational therapy and an intensive rehabilitation program for at least 
three hours per day, five days per week. It is not clear that the enrollee is ready for discharge at this time and 
can be reasonably expected to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 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 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 pay for the office visit provided on July 12, 2021, by an out-of-network
(OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 12, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
 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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record 
indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new start. Our reviewer 
found that the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step 
one alternative, Orthovisc or Supartz FX. 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. Our physician reviewer also 
found that 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee is on a home ventilator to keep CO2 
out of her body. She is using the device every day and really feels she is benefiting from this device. The Plan 
denied your request. The Plan says the records do not support that the enrollee meets the criteria. 
 
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 looked at 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 
home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a negative pressure wound therapy pump 
provided on January 8, 2020. 
 
You asked the Plan to waive the coinsurance for the negative pressure wound therapy pump. You say that the 
services should be covered as the claim reprocessed incorrectly. The Plan denied your request. The Plan says 
the cost-sharing applied correctly based on the services 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 a 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
 
 
 You have been asked to pay a 20% coinsurance for a negative pressure wound therapy pump (allowed is 
$409.2 x 20% = $81.84). Negative pressure wound therapy pumps fall within the Durable medical equipment 
(DME) and related supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a negative 
pressure wound therapy pump provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 2, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code.  Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (80307,82542, 84228 and G0480)  
provided on October 11, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says these services were received out-of-
network and prior authorization was not obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the drug testing services (80307,82542, 84228 and 
G0480)  provided on October 11, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kadcyla (J9354) to be used in combination with 
Keytruda (J9271). 
 
You asked the Plan to pre-approve Kadcyla. You say that the enrollee would potentially benefit from Kadcyla. 
The Plan denied your request. The Plan says this drug is experimental/investigational for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Kadcyla. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of stage IV bladder cancer. The 
Food and Drug Administration has not stated that either the requested drug or the requested regimen is 
indicated for the enrollee's condition. Our reviewer found that the Medicare approved cancer drug compendia 
do not contain a supportive citation for the use of the requested drug or the requested regimen in the enrollee's 
clinical situation. Our physician reviewer also found that no literature from Medicare approved cancer journals 
were submitted for review in support of use of the requested drug or the requested regimen.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kadcyla have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kadcyla (J9354) to be used in combination with Keytruda (J9271).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound coded as 76705 provided on 
October 29, 2021. 
 
You asked the Plan to pay for the abdominal ultrasound. You say that this is medically reasonable for the 
enrollee's condition. The Plan denied your request. The Plan says this claim has not been billed with an 
appropriate modifier as required by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound coded as 76705 provided on October 
29, 2021.