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

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Aranesp. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Aranesp. Our physician reviewer found the requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step one alternative. Our reviewer also found that 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic 
spine. 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that in this case, the record indicates that the 
enrollee has cognitive impairment. The record does not indicate the presence of any thoracic complaints, 
pathology, or that the provider intended to order the requested study. 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the thoracic spine.
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. You say that the enrollee has tried and failed corticosteroid 
injections. 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 the 
enrollee does not meet the criteria for coverage for Euflexxa. Our physician reviewer found the requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step one alternative. Our reviewer also found that 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. 
 
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: 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 enrollee would like reconsideration based on 
records submitted. The Plan denied your request. The Plan says a SNF admission is not medically necessary, 
and the enrollee's needs can be met in an alternate level of 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursingor skilled therapy needs. The 
enrollee's care needs can be provided at a lower 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 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 Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Injectafer. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Injectafer. Our physician reviewer found the requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step one alternative. Our reviewer also found that 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided on 
June 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that based on the information provided, please 
reconsider the denial of the OneOme RightMed test as not medically necessary. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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. Also, per Local Coverage Determination (LCD) Molecular Pathology Procedures L35000 
MTHFR (5,10-methyenetetrahydrofolate reductase) (e.g. hereditary hypercoaguability), gene analysis, common 
variants (e.g., EG, 677T, 1298C) is not considered to be clinically efficacious; therefore, testing is not 
medically necessary. 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 unlisted molecular pathology procedure (81479) 
provided on June 21, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation (P-Stim) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has a complete loss of medial joint 
space. The Plan denied your request. The Plan says this is experimental, investigational, and unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered an experimental/investigational therapy. Therefore, the request is deemed not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve peripheral nerve stimulation (P-Stim) for the enrollee.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from October 30, 2021, to November 
24, 2021. 
 
You asked the Plan to pay for home health services. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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, the Plan has not indicated the rules supporting their denial nor 
provided information on how the claim at issue might be corrected. It is the Plan's responsibility to substantiate 
its denial. In this case, the Plan's denial has not been substantiated, so we must find in your favor. Therefore, 
we decided that the Plan has to pay for home health services provided from October 30, 2021, to November 24, 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that this service is medically necessary. The 
Plan denied your request. The Plan says you have exhausted the allowable benefit for this service. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from July 27, 2022, through 
November 3, 2022. The Plan has approved 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam by a pathologist (88305) provided on 
November 1, 2021. 
 
You asked the Plan to pay for the tissue exam by a pathologist. You say that this service should be paid. The 
Plan denied your request. The Plan says this provider is restricted from providing services to 
Medicare/Medicaid members per the Office of Inspector General exclusion data base. 
 
The Plan must follow Medicare rules. The rules say that Medicare will not pay a claim for sanctioned/excluded 
physician or practitioner services. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
is excluded from the Medicare program. Therefore, we decided that the Plan does not have to pay for the tissue 
exam by a pathologist (88305) provided on November 1, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 testing (81479) provided on April 7, 2022. 
 
You asked the Plan to pay for Guardant360 testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that the date-of-service should be reported as the date the specimen was 
collected. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case of a molecular pathology test 
performed by a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT, the date 
of service must be the date the test was performed if the criteria in the Medicare Rules section of this letter are 
met. 
 
In this case the laboratory test performed is considered an ADLT. The sample in this case was collected during 
a hospital outpatient counter. Therefore, the date-of-service was correctly reported as the date the test was 
performed, April 7, 2022. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have been met. Therefore, we decided that the Plan has to pay for Guardant360 testing 
(81479) provided on April 7, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 24 one-way trips 
allowed for the 2022 benefit year and additional trips will not be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a bunionectomy (28296). 
 
You asked the Plan to pre-approve a bunionectomy. You say that the requested service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 a bunionectomy. Our reviewer says that 
the requested service is considered medically reasonable and necessary in this case. Our physician reviewer 
found that, although the enclosed progress note is not detailed, a diagnosis of hallux valgus is made. The 
enrollee states that their hallux valgus is causing them pain both in and out of shoes. The enrollee's painful 
hallux valgus deformity meets Medicare guidelines as a malformed body member. The surgery requested meets 
the guidelines for covered treatment and is considered standard of care treatment for a painful hallux valgus 
deformity. 
 
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 bunionectomy have been met. Therefore, we decided that the Plan has to pre-
approve a bunionectomy (28296).  
 
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: 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 admission to the IRF 
was denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate. 
Skilled nursing facility level of care was offered. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  Your medical status does not require intensive physician and nursing oversight in an IRF. While you may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal you require this therapy on an intensive IRF level. 
 
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 blood pressure monitor (A4670). 
 
You asked the Plan to pre-approve a blood pressure monitor. You say that you have to poke your finger every 
time you take a test, and you feel the devise is outdated. You would like to take control of your health as it is 
difficult for you to know when your pressure goes up or down. The Plan denied your request. The Plan says 
there is no documentation/evidence you are on dialysis or have ESRD. The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitor (A4670).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopic shoulder surgery. 
 
You asked the Plan to pre-approve arthroscopic shoulder surgery. You say that arthroscopic shoulder surgery is 
medically necessary. The Plan denied your request. The Plan says this surgery is not medically necessary. An 
imaging study (computed tomography (CT) or magnetic resonance imaging (MRI)) that shows a problem in the 
shoulder (SLAP, Bankart injury, or full-thickness subscapularis tear) that matches symptoms and a doctor 
exam are needed. 
 
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 arthroscopic shoulder surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this 65-year-old female was being treated for impingement syndrome of the 
right shoulder. She presented with right shoulder pain that is anterolateral. The exam reveals tenderness of the 
biceps. The range of motion is 170 in abduction and flexion. Speeds is positive as is impingement testing. 
However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures including medications. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthroscopic shoulder surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthroscopic shoulder surgery.