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

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of iron deficiency anemia with decreased absorption of oral iron. The 
documentation does not support that the enrollee has tried and failed Infed (iron dextran) and Venofer (iron 
sucrose). The documentation does not support that Infed (iron dextran) or Venofer (iron sucrose) 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service August 22, 
2021. 
 
You asked the Plan to pay for procedure code 99221. You say that this is a payable service. The Plan denied 
your request. The Plan says this is not a payable service because the provider already billed an evaluation and 
management code for this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare only pays physicians for one hospital 
visit per day for the same patient, whether the problems seen during the encounter are related or not.  In this 
case, the provider already billed for a hospital visit (code 99223) on this same date of service. We looked at the 
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99221 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99221 billed for date of service August 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Intracept is experimental for lower back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you have never adjusted your insulin 
dosages and have always tested 3-4 times a day as your doctor advised. You also say your blood sugar is very 
low and you really need to keep track of your sugar accurately. The Plan denied your request. The Plan says 
you do not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results or have had an in-person 
visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 
Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) 
and supplies (K0553, K0554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on January 12, 
2022. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (0037U) provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collagen dressing (A6021) and the foam dressing 
(A6212) provided on April 7, 2021. 
 
You asked the Plan to pay for codes A6021 and A6212. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say all services billed by the SNF (including those 
furnished under arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay are 
included in the SNF's Part A bill. 
 
We looked at the file and Medicare rules. The file shows the billed services for April 7, 2021, are not listed as 
excluded from consolidated billing. The enrollee was inpatient at a participating SNF on this date of service. 
The billed services should be included in the SNFs bill. Therefore, we decided that the Plan does not have to 
pay for the collagen dressing (A6021) and the foam dressing (A6212) provided on April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. 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 certain cardiac event monitors capture electrical 
activity with a single electrode attached to the skin.  
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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a recent randomized clinical trial 
found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral 
anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic 
embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. At this 
time, insertion of an ILR would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on February 23, 
2022. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (0037U) provided on February 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that this drug is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for this drug have not been met. 
 
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 Imfinzi. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with right lung stage IIIA small-cell lung cancer. In this case, the requested use of Imfinzi is not 
FDA-approved for the enrollees diagnosis as there is no documentation of stability or improvement after 
completion of chemotherapy and radiation. Furthermore, the use of Imfinzi is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone Sodium Phosphate, Liposomal 
Doxorubicin, and Bevacizumab-AWWB. 
 
You asked the Plan to pre-approve Dexamethasone Sodium Phosphate, Liposomal Doxorubicin, and 
Bevacizumab-AWWB. You say that the requested Dexamethasone Sodium Phosphate, Liposomal 
Doxorubicin, and Bevacizumab-AWWB is medically necessary. The Plan denied your request. The Plan says 
the requested Dexamethasone Sodium Phosphate, Liposomal Doxorubicin, and Bevacizumab-AWWB is not 
medically necessary. 
 
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 Dexamethasone Sodium Phosphate, 
Liposomal Doxorubicin, and Bevacizumab-AWWB. Our reviewer says that the requested Dexamethasone 
Sodium Phosphate, Liposomal Doxorubicin, and Bevacizumab-AWWB is not medically necessary. Our physician reviewer found the requested use of Dexamethasone Sodium Phosphate, Liposomal Doxorubicin, 
and Bevacizumab-AWWB is not FDA-approved for the enrollee's diagnosis. The use of these drugs is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. The request is not a standard regimen for uterine carcinosarcoma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dexamethasone Sodium Phosphate, Liposomal Doxorubicin, and Bevacizumab-
AWWB have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone 
Sodium Phosphate, Liposomal Doxorubicin, and Bevacizumab-AWWB.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
October 26, 2021, through November 23, 2021. 
 
You asked the Plan to pay for the SNF services provided. You say that the billed SNF care was medically 
necessary on the dates in question. The Plan denied your request. The Plan says no skilled therapy or nursing 
services were rendered during these dates of service.  
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 pay for the SNF services provided. Our reviewer 
says that the SNF care provided was not medically reasonable and necessary. Our physician reviewer found 
that based on the documentation provided, the enrollee no longer qualified for SNF coverage. The enrollee did 
not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs.  
Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial and intermittent, could, as a practical matter, 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 the SNF services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided from October 26, 2021, 
through November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional portable oxygen concentrator. 
 
You asked the Plan to pre-approve an additional portable oxygen concentrator. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than 1 unit of service (UOS) for 
stationary contents and/or 1 UOS for portable contents per month are billable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an additional portable oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 prosthetic knee and foot (L5828, L5845, L5848, 
L5986, L5981). 
 
You asked the Plan to pre-approve the K3 prosthetic knee and foot. You say that the components are medically 
necessary. The Plan denied your request. The Plan says the requested features exceed the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of prosthesis. 
 
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 K3 prosthetic knee and foot. Our 
reviewer says that the requested prosthetic components are not medically necessary. Our physician reviewer 
found the provided records do not support that the enrollee meets criteria as a K3 ambulator. Records do not 
support damage to the current prosthesis. 
 
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 K3 prosthetic knee and foot have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a K3 prosthetic knee and foot (L5828, L5845, L5848, L5986, L5981).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health visit (90837) provided on March 
15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health visit. You say that these services were referred by 
your previous PCP. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
 
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 outpatient mental health visit (90837) provided 
on March 15, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
March 8, 2022, through March 21, 2022. 
 You asked the Plan to pay for the billed SNF services. You say that the SNF care provided was medically 
necessary. The Plan denied your request. The Plan says there was no daily need for skilled services. 
 
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 pay for the billed SNF services. Our reviewer says 
that the SNF care provided was not medically reasonable and necessary. Our physician reviewer found that 
based on the documentation provided, the enrollee no longer qualified for SNF coverage. The enrollee did not 
have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily 
skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs were custodial and could, as a practical matter, 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 the billed SNF services have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing facility (SNF) services provided from March 8, 2022, through 
March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (81455) provided on January 27, 2022. 
 
You asked the Plan to pay for code 81455. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will 
be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical 
management of the enrollee. Therefore, we decided that the Plan does not have to pay for the genetic testing 
(81455) provided on January 27, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has 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. The case file was requested and never received from the health plan. Without 
this information, the plan's denial is not able to be substantiated. Therefore, we decided that the Plan has to pre-
approve skilled nursing facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the device is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 portable ventilator. Our reviewer 
says that the requested device is not medically necessary. Our physician reviewer found the Life2000 system is 
not medically necessary. This system is not a true ventilator, because it is not capable of providing full 
ventilatory support. There is inadequate evidence that it is beneficial in the treatment of any chronic lung 
disease. 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).