Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injections. 
 You asked the Plan to pre-approve the Orthovisc treatments. You say that this drug is necessary due to failure 
of the preferred brand and risk of pseudoseptic shock associated with another. The Plan denied your request. 
The Plan says Durolane would be acceptable and is one of the preferred drugs. 
 
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 the Orthovisc treatments. Our reviewer 
says that the requested drug is not medically necessary based on the step therapy rules. Our physician reviewer 
found the Plan requires a trial of drug Durolane before they will approve the requested drug. In this case, the 
patient has not tried and failed the required drug(s). There is no documentation provided indicating that the 
plans required drug(s) 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 the Orthovisc treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Orthovisc injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve palonosetron HCl.  
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says clinical trial services are covered by Original Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare pays for the routine costs of qualifying 
clinical trials. 
 
We looked at the file and Medicare rules. The requested services are part of a clinical trial. These services must 
be covered by Original Medicare and not the Plan. Therefore, we decided that the Plan does not have to pre-
approve palonosetron HCl.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from July 18, 2022, through August 
16, 2022. 
 
You asked the Plan to pay for the home health services. You say that the documentation supports payment for 
these services. The Plan denied your request. The Plan says that the orders do not include a course of therapy 
treatment and include measurable therapy treatment goals. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says 
that the services are shown to be medically reasonable and necessary. Our physician reviewer found the 
enrollee received a home health occupational therapy evaluation on 7/22/2022. An addendum page to this visit 
notes interventions and goals. A second submitted copy of the visit includes a physician signature. As such, the 
health plan has failed to support its argument. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
has to pay for the home health services provided from July 18, 2022, through August 16, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve the Euflexxa injections. You say that the enrollee is not able to try steroid 
injections due to blood pressure issues. The Plan denied your request. The Plan says criteria for the use of this 
treatment are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the Euflexxa injections. Our reviewer 
says that the requested treatment is not medically necessary at this time. Our physician reviewer found ore 
conservative measures including a 12-week trial of physical therapy is needed. A steroid injection may also be 
tried despite blood pressure issues as steroid injection does not affect blood pressure. 
 
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 Euflexxa injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Euflexxa injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Margenza (margetuximab-cmkb) treatments. 
 
You asked the Plan to pre-approve the Margenza treatments. You say that this treatment is medically 
necessary. The Plan denied your request. The Plan says this drug is not medically accepted for use as 
monotherapy. 
 
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 the Margenza treatments. Our reviewer 
says that the requested treatment is not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of triple positive breast cancer which is metastatic to the lung and brain. The enrollee has been treated with mastectomy, multiple lines of chemotherapy, craniotomy, and radiation therapy. There is evidence 
of progression of disease. 
 
Margenza is indicated, in combination with chemotherapy (capecitabine, eribulin, gemcitabine, or vinorelbine), 
for the treatment of adult patients with metastatic HER2-positive breast cancer who have received two or more 
prior anti-HER2 regimens, at least one of which was for metastatic disease. However, the appeal in this case is 
for Margenza to be used as monotherapy. There is insufficient support in the major drug compendia or in the 
medical literature for the use of single agent Margenza in the treatment of metastatic breast cancer. There is 
insufficient evidence in the medical literature to support that Margenza is medically reasonable and necessary 
for the enrollee in this case. 
 
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 Margenza treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Margenza (margetuximab-cmkb) treatments.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need a stretcher for 
transportation. The Plan denied your request. The Plan says you have exhausted your transportation benefit. 
 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 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 trips for routine transportation beyond the Plan's 
24-trip limit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan injections for the shoulder. 
 
You asked the Plan to pre-approve the requested use of Hyalgan. You say that this should be approved as it will 
be helpful for the enrollee's condition. The Plan denied your request. The Plan says this is not approved for 
treatment of shoulder arthritis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the requested use of Hyalgan. Our 
reviewer says that the requested use of Hyalgan is not medically necessary. Our physician reviewer found 
viscosupplementation injections are experimental in the shoulder region at this time. 
 
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 requested use of Hyalgan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Hyalgan injections for the shoulder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has sacroilitis. The use of 
SI joint RFA is considered experimental/investigational in nature due to wide variation in efficacy reported in 
peer reviewed literature. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 20985) rendered on October 31, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the services do not meet the coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 20985 is "Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less 
(List separately in addition to code for primary procedure)." 
 
We asked our coder 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 services. Our reviewer says that the services as issue in 
this case were supported by the medical records. Our reviewer found that the operative report documents 
computer assisted surgical navigational procedure was used for total hip replacement.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 20985) rendered on October 31, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laminotomy services (procedure code 63042 and 63044) 
rendered on December 14, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says all the procedures were performed in the same levels of L4-S1 and therefore the laminectomy is 
inclusive to the arthrodesis procedures. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 63042: 
 
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 
foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar 
 
 CPT 63044: 
 
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 
foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional 
lumbar interspace (List separately in addition to code for primary procedure) 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report describes a 
redo lumbar laminectomy with facetectomy and foraminotomy at L4-5 and L5-S1, as well as arthrodesis at 
same level. In this case, arthrodesis is the more comprehensive service and would include laminotomy with 
decompression. The operative report does not support decompression beyond what is required to prepare the 
interspace for fusion. In this case, this service was unbundled from the more comprehensive procedure, and 
therefore denied correctly. 
 
We looked at this coder'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 pay for laminotomy services (procedure code 63042 and 63044) rendered on December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kidney flow/function imaging. 
 
You asked the Plan to pre-approve kidney flow/function imaging. You say that this scan is needed to make sure 
your cancer hasn't spread. The Plan denied your request. The Plan says there is no indication for this study in 
your medical records. 
 
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 kidney flow/function imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the medical records show a bone scan, so it is not clear if this was an 
ordering mistake for a patient with prostate cancer.  There is no explanation or indication for the requested 
kidney study.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kidney flow/function imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve kidney flow/function imaging.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve SNF care. You say that the member has a hip fracture and needs 
rehabilitation to regain function. The Plan denied your request. The Plan says requested care can be provided 
by a SNF in-network. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
SNF care to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy and upper endoscopy provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you do not want to see the network provider. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The file shows that the network provider is 
located 16.2 miles from your residence, which is within Medicare distance guidelines. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy and upper endoscopy provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the Dexcom G6 CGM. You say that you need this device. The Plan denied 
your request. The Plan says you do not meet criteria for this device because you do not require multiple daily 
doses of insulin. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, 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 the Dexcom G6 CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor 
(CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel the enrollee needs intensive therapy at a 
higher level of care. The Plan denied your request. The Plan says the IRF services you are requesting do not 
meet the requirements for approval. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/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 inpatient rehabilitation facility (IRF) admission and services.