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

 
We decided that the Plan does not have to pre-approve Retacrit (Q5105). 
 
You asked the Plan to pre-approve Retacrit. You say that the enrollee is behind on their treatment. The Plan 
denied your request. The Plan says no support was found in the compendia for the requested use of Retacrit. 
The Plan also says this drug is not covered per Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Retacrit. Our reviewer says that 
Retacrit is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of unspecified anemia and history of iron deficiency, now corrected. 
The FDA has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found 
that 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. Our physician 
reviewer also found that 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5105).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C (J1561). 
 
You asked the Plan to pre-approve Gamunex-C. The Plan denied your request. The Plan says there was no 
record provided that shows the enrollee has tried the preferred drug, Privigen, and it has not worked, or that the 
enrollee has medical reasons that prevent them from using it. 
 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 Gamunex-C. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Gamunex-C. Our physician reviewer found the Plan 
requires a trial of drug Privigen before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drug. Our reviewer also found that there is no documentation provided indicating 
that the Plans 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 Gamunex-C have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C (J1561).
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 enrollee would benefit from 3 hours of physical 
and occupational therapy. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's 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 the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor controlled ankle foot system. 
 
You asked the Plan to pre-approve a microprocessor controlled ankle foot system. 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 a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 microprocessor controlled ankle foot 
system. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
physician documentation does not support the need for a microprocessor foot. Your needs and daily activities 
can be met with a mechanical foot. The documentation does not reveal that the existing foot is damaged and 
needs replacement and it is still under warranty. 
 
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 microprocessor controlled ankle foot system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a microprocessor controlled ankle foot system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the ventilator was ordered 
because the enrollee needs a device that can provide volume assisted pressure support settings to guarantee that 
they receive a targeted tidal volume with every breath. You also say that continuous positive airway pressure 
(CPAP) and bilevel positive airway pressure (BiPAP) were considered but determined to be insufficient for the 
enrollee's needs. The Plan denied your request. The Plan says this request for a home mechanical ventilator set 
in volume-assured pressure support (VAPS) mode that could be delivered by 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 a home mechanical ventilator. Our 
reviewer says that a home mechanical ventilator is not medically reasonable and necessary for the enrollee. Our 
physician reviewer found there is a diagnosis of obesity hypoventilation syndrome and obstructive sleep apnea. 
There is no documented history of COPD, and no pulmonary function test results. There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. Our reviewer found that there is no arterial blood gas 
analysis (ABG) done while stable to document chronic carbon dioxide (CO2) retention. If this enrollee does 
have chronic CO2 retention, they may benefit from BiPAP during sleep as an outpatient. The records do not 
show that this has been tried and failed as an outpatient. Our physician reviewer also found that Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP, or for the diagnosis of 
obesity hypoventilation syndrome. 
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that a lumbar epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says a lumbar epidural steroid 
injection does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 lumbar epidural steroid injection. Our 
reviewer says that a lumbar epidural steroid injection is not medically necessary in this case. Our physician 
reviewer found that you received an L4-L5 epidural steroid injection on December 9, 2022, which provided 
75% pain relief for 3 weeks. The Medicare LCD criteria is 3 months of 50% pain relief. This has not yet been 
achieved and therefore, the request is deemed not medically reasonable and 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 a lumbar epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says the requested genicular nerve block is not 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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that you have a history of bilateral knee pain due to bilateral osteoarthritis of the 
knee. You have tried and failed conservative treatment. Genicular nerve blocks and genicular nerve 
radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic 
knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the 
knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for 
individuals who are not candidates for knee replacement surgery. The review has determined that the requested 
genicular nerve radiofrequency ablation is 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second pair of diabetic shoes with inserts. 
 
You asked the Plan to pre-approve a second pair of diabetic shoes with inserts. You say that you need the 
diabetic shoes as soon as possible because you have been waiting since last year. The Plan denied your request. 
The Plan says you have exhausted your calendar year benefit for diabetic shoes and inserts as of January 10, 
2023. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Although foot orthotics are not generally covered by Medicare, your plan offers a supplemental benefit for one 
pair of diabetic shoes with two additional pairs of inserts per calendar year. The record shows that you received 
diabetic shoes and inserts on January 10, 2023, and this benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pre-approve a second pair of diabetic shoes with inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement nebulizer with compressor. 
 
You asked the Plan to pre-approve these services. You say that your current machine is on recall. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment is 
covered in the case of irreparable damage or when the equipment as exceeded the reasonable lifetime period of 
five years. 
 
We looked at the file and Medicare rules. The file shows that your current nebulizer with compressor is not 
more than five years old and you confirmed that it is working properly. The Plan confirmed with the 
manufacturer that the device is not on recall. Replacement of this device does not meet the Medicare rules for 
coverage. Therefore, we decided that the Plan does not have to pre-approve a replacement nebulizer with 
compressor.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. You say that the requested sleep study is medically necessary. 
The Plan denied your request. The Plan says that the services are not covered. 
 
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. Specifically, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide any medical records in 
order to determine if the enrollee meets Medicare criteria for the requested sleep study. Therefore, we decided 
that the Plan has to pre-approve a sleep study.  
 
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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services rendered on August 19, 2021. 
 
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 that the claim is a duplicate. 
 
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 states that the claim is a duplicate; however, an Explanation of Benefits 
(EOB) for the processed claim has not been submitted. There is no documentation to support that the services 
were previously paid. Therefore, we decided that the Plan has to pay for the emergency room (ER) services 
rendered on August 19, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 21, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for hospital-to-
hospital transfer and is appropriate for extended acute care. The Plan denied your request. The Plan says when 
ready to leave the hospital, the enrollee's needs may be safely received in another setting, a Skilled Nursing 
Facility (SNF) or at home with home health services or outpatient setting if appropriate 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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 a home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee has a 
diagnosis of severe chronic obstructive pulmonary disease (COPD). The enrollee was recently admitted with a 
COPD exacerbation and possible pneumonia. The appeal note indicates that they have been unable to obtain an 
arterial blood gas (ABG), so there is no documentation of chronic CO2 retention. The appeal note also mentions "severe myopathy". However, on her previous admission a neurology consultant did not mention any 
findings of generalized muscle weakness and there was no mention of a systemic myopathy or other 
generalized neuromuscular disease. The total carbon dioxide level in the venous blood has been within normal 
limits on multiple occasions, making chronic CO2 retention unlikely. This enrollee does not meet criteria 
establishing need for nocturnal ventilatory support. If the enrollee was found to have chronic CO2 retention, 
she may benefit from BiPAP with AVAPS during sleep.  However, Medicare does not cover a home ventilator 
when used at settings that can be provided with 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacro-iliac radiofrequency ablation procedure (99152, 
64625, 64635). 
 
You asked the Plan to pre-approve the ablation procedure. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service is experimental and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Radiofrequency ablation used for sacro-iliac 
joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency. 
 
We looked at the file and Medicare rules. This procedure is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the ablation procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a sacro-iliac radiofrequency ablation procedure (99152, 64625, 
64635).