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

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies provided on 
November 4, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the records support that this claim is payable. 
The Plan denied your request. The Plan says that the documentation submitted did not include valid Proof of 
Delivery or a Delivery Ticket to indicate the specific supplies provided. 
 
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 has indicated that this is denied because of a lack of a valid proof of 
delivery. However, the supplier has provided a document showing that two 14-day supplies of sensors were 
delivered on November 4, 2021, and signed for by the enrollee. We find that the rationale provided by the Plan 
is not substantiated. Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) 
supplies provided on November 4, 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 cardiovascular genetic testing provided on June 18, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hyalgan Supartz (J7321). 
 
You asked the Plan to pre-approve Hyalgan Supartz. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested drug have not 
been met. 
 
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 Hyalgan Supartz. Our reviewer says 
that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found 
that the request is an off-label use of the medication and is not supported by evidence-based literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan Supartz have not been met. Therefore, we decided that the Plan does 
not have to pre-approve treatment with Hyalgan Supartz (J7321).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee is improving but still requires acute care services. The enrollee continues 
to receive acute care services, and these have not been denied. The medical record does not indicate that the 
enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee does not require skilled nursing 
services. The documentation does not support that it is medically reasonable and necessary to provide skilled 
services on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis, in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim system (0266T). 
 
You asked the Plan to pre-approve a Barostim system. You say that the requested item/service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 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 a Barostim system. Our reviewer says 
that the requested item/service are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that Barostim therapy is indicated for the improvement of symptoms of heart failure 
(quality of life, six-minute hall walk, and functional status) for patients who remain symptomatic despite 
treatment with guideline-directed medical therapy, are NYHA Class III or Class II (who had a recent history of 
Class III), have a left ventricular ejection fraction less than or equal to 35%, a NT-proBNP hormone level of 
less than 1600 pg/mL, and excluding patients indicated for Cardiac Resynchronization Therapy (CRT). The 
enrollee in this case has already had a Cardiac Resynchronization Therapy placed. 
 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 Barostim system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Barostim system (0266T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Multaq tablet. 
 
You asked the Plan to pre-approve Multaq. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Multaq 
tablet.  
 Benefits for Multaq 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 treatment with Oxycodone-Acetaminophen tablet. 
 
You asked the Plan to pre-approve Oxycodone-Acetaminophen. You say that the requested drug is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered 
drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Oxycodone-
Acetaminophen tablet.  
 Benefits for Oxycodone-Acetaminophen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and armrests. 
 
You asked the Plan to pre-approve an expandable controller, harness, and armrests. 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 wheelchair accessories are covered when specific 
criteria are met. 
 
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 expandable controller, harness, and 
armrests. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
on the medical records provided there is no documentation that you meet the coverage criteria for the requested 
power wheelchair accessories as detailed in the Local Coverage Determination E2377, expandable controller 
and E2323, harness is not approved as no specialty controller has been requested or approved. E0973 x 2 
armrests are not covered as this is a duplicate request - armrests are included in E1002, power tilt. 
 
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 expandable controller, harness, and armrests have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller, harness, and armrests.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT genetic testing panel of 648 genes provided 
on September 19, 2020. 
 
You asked the Plan to pay for the Tempus xT genetic testing panel. You say that this was medically necessary 
testing. The Plan denied your request. The Plan says this panel should be billed with a single code for the panel, 
not individual gene codes 
 
The Plan must follow Medicare rules. Medicare rules say that when multiple genes are tested in parallel, 
providers should report this with a single genetic testing code. 
 
 
 
 
  
In this case, the panel provided tests 648 genes in parallel but was incorrectly billed with multiple gene codes. 
Therefore, we decided that the Plan does not have to pay for the Tempus xT genetic testing panel of 648 genes 
provided on September 19, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 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 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires step therapy with Orthovisc or Supartz FX. The enrollee has not had trials of Orthovisc or Supartz 
FX and does not have a contraindication to a trial of these medications. 
 
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 treatment with Euflexxa (J7323).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 70 hours of home health services. 
 
You asked the Plan to pre-approve home health services. You say that you have a need for the requested care. 
The Plan denied your request. The Plan says rules for coverage for home health services have not been met. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 70 hours 
of home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Aloxi (J2469). 
 
You asked the Plan to pre-approve Aloxi. You say that the requested drug is a medical necessity for the 
enrollee as there are no suitable alternatives. The Plan denied your request. The Plan says rules for coverage for 
the requested 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 Aloxi. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Aloxi is not FDA-approved for the enrollees diagnosis because the enrollee's 
chemotherapeutic regimen has low emetogenic potential and there is no documentation that the enrollee has 
other risk factors for nausea/vomiting. Furthermore, the use is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-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 Aloxi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Aloxi (J2469).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracorporeal photopheresis services provided on 
November 3, 2021. 
 
You asked the Plan to pay for the extracorporeal photopheresis services. You say that the enrollee's condition 
causes lung damage consistent with bronchiolitis obliterans, and this photopheresis treatment is the only thing 
that has provided sustained relief. The Plan denied your request. The Plan says this treatment is not covered by 
Medicare for the enrollees condition. 
 
The Plan must follow Medicare rules. Medicare rules say that extracorporeal photopheresis is only covered for 
the conditions listed in the Medicare rules section of this decision.   
We looked at the file and Medicare rules. Although the enrollees condition may cause bronchiolitis obliterans, 
there is no evidence that the enrollee has had a lung transplant. In addition, the enrollee is not participating in 
the required clinical study. Based on this information, we decided that Medicare rules for coverage of the 
extracorporeal photopheresis services have not been met. Therefore, we decided that the Plan does not have to 
pay for the extracorporeal photopheresis services provided on November 3, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Lupron Depot (J9217). 
 
You asked the Plan to pre-approve Lupron Depot. You say that the requested drug is a medical necessity for 
you. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met. 
 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 Lupron Depot. Our reviewer says that 
the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
the Plan requires a trial of drug Eligard before they will approve the requested drug. The case file does not 
contain documentation of trial and failure of Eligard. The available documentation does not support that 
Eligard would likely be less effective and/or would likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Lupron Depot (J9217).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ongentys capsule. 
 
You asked the Plan to pre-approve Ongentys. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Ongentys 
capsule.  
 Benefits for Ongentys 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute 
exacerbations of chronic medical problems. His physical function is at or near his baseline. The enrollee does 
not require skilled nursing and/or skilled therapy services on a daily basis. Although further rehab services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing facility. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation, per quadrant (D4921). 
 
You asked the Plan to pre-approve gingival irrigation, per quadrant. You say that you have an upcoming 
appointment, and you cannot afford the irrigation. You do not wish to wait longer with a new provider. The 
Plan denied your request. The Plan says the services requested are not listed as a covered benefit with your 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation, per quadrant (D4921).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on September 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says an appropriate RAPs 
claim was not submitted for period of care. 
 
The Plan must follow Medicare rules. Medicare rules say that All Home Health Agencies (HHAs) must submit 
a request for anticipated payment within 5 calendar days after the start of care date for initial 30-day periods 
and within 5 calendar days after the from date for each subsequent 30-day period of care.  
 
We looked at the file and Medicare rules. In this case, a RAP claim was not submitted within the required time 
frame. 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 pay for the home health services provided on 
September 21, 2021.