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

 
We decided that the Plan does not have to pre-approve Ozurdex. 
 
You asked the Plan to pre-approve Ozurdex. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use is not supported. 
 
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 Ozurdex. Our reviewer says that the 
requested use of Ozurdex is not supported. Our physician reviewer found Ozurdex is not Food and Drug 
Administration-approved for your condition, congenital glaucoma of both eyes with hypotony of the left eye 
and no evidence of eye inflammation. It is also 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 Ozurdex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ozurdex.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory (lab) services provided on January 24, 2022. 
 
You asked the Plan to pay for lab services. The Plan denied your request. The Plan says original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory (lab) services provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapy services from November 19, 2021, 
through December 23, 2021. 
 
 
You asked the Plan to waive the copayment for therapy services. You say that you are requesting a second look 
at the claims and that you feel you have met your maximum out of pocket at the time of service. The Plan 
denied your request. The Plan says based on members claim history, member did not meet the maximum out of 
pocket at that time of services, so the claim was processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each Medicare-covered therapy visit.  
 
You have been asked to pay a $30 copayment for therapy services. Therapy services fall within the Outpatient 
rehabilitation services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for therapy 
services from November 19, 2021, through December 23, 2021.
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 you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the records show that you were 
admitted to the hospital on August 8, 2022 and underwent a left below-knee amputation on August 10, 2022. 
You were re-admitted to the hospital August 27, 2022 after a fall and had revision to the amputation. The 
physical and occupational therapy notes state that you need assistance with functional transfers, dressing, and 
sitting up and standing. You have ongoing wound care needs and require skilled nursing on a daily basis for 
this care. You have skilled therapy needs and require skilled therapy on a daily basis for strength, endurance, 
adaptive techniques, and durable medical equipment (DME) assessments. As a practical matter, you require the 
necessary services on an inpatient basis at the SNF 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services coded 76830 provided on January 18, 
2022. 
 
You asked the Plan to pay for the ultrasound services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 29, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the ultrasound services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound services coded 76830 provided on 
January 18, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. The Plan denied your request. The Plan says that 
the enrollee does not have capacity to respond to daily skilled therapy with material gains within a predictable 
time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer 
says that 10 additional PT sessions are medically necessary. Our physician reviewer found the clinical 
documentation shows that the enrollee has not met all of their therapy goals, and is working on standing trials 
complicated by balance impairment, vertigo and vasovagal issues. Our reviewer also found that this would 
require the expertise of a specialized therapist to progress on stated goals. 
 
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 additional PT visits have been met. Therefore, we decided that the Plan has 
to pre-approve 10 additional physical therapy (PT) visits.  
 
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 Gammagard (J1569). 
 
You asked the Plan to pre-approve Gammagard. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not approved by the FDA for the 
enrollee's condition. 
 
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 Gammagard. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the requested drug is not Food and 
Drug Administration-approved for the enrollee's diagnosis. The reviewer found that the use of Gammagard for 
the enrollee's condition is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested drug is not 
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 Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard (J1569).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair (K0814) provided June 17, 2021. 
 
You asked the Plan to pay for the power wheelchair. You say that the power wheelchair was 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 Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a power wheelchair (K0814) provided 
June 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One injection. 
 
You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is necessary. The Plan denied 
your request. The Plan says the criteria for coverage 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 Synvisc-One. Our reviewer says that 
the step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the required treatments of acetaminophen or a non-steroidal anti-
inflammatory drug and nonpharmacologic therapy (such as a home exercise program or physical therapy). The 
reviewer found that the medical records provided, and the Medicare-approved major drug compendia do not 
indicate that the plan's required treatments would likely be less effective and/or likely have adverse effects for 
the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on October 1, 
2021. 
 
  You asked the Plan to pay for moderate sedation services (99153). You say that these were performed on an 
emergent basis and should be reviewed for payment. The Plan denied your request. The Plan says procedure 
codes 92941, 93458 and 92978 have been overturned. The Plan also says that procedure code 99153 may not 
be paid if furnished to hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, these were performed on an 
emergent basis and should be reviewed for payment. Based on this information, we decided that Medicare rules 
for coverage of moderate sedation services (99153) have not been met. Therefore, we decided that the Plan 
does not have to pay for moderate sedation services (99153) provided on October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on March 16, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation did not support the billed codes. 
 
The Plan must follow Medicare rules. The rules state that if the information in the patients medical record does 
not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved.  The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The medical records do not show the provided orthoses as part 
of the enrollees treatment plan. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses provided on 
March 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pluvicto, (A9699) once every week for 6 weeks. 
 
You asked the Plan to pre-approve Pluvicto. You say that you would like to receive radiation therapy instead of 
chemotherapy. You say that you do not trust chemotherapy. You also say that you believe that radiation 
therapy is the answer to your cancer. The Plan denied your request. The Plan says the requested drug is not 
approved by the FDA for your diagnosis. 
 
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 Pluvicto. Our reviewer says that the 
requested drug, Pluvicto, is not medically necessary. Our physician reviewer found Pluvicto is not Food and 
Drug Administration (FDA)-approved for the enrollee's condition with no prior history of taxane-based 
chemotherapy. The reviewer found that the requested use with no prior history of taxane-based chemotherapy 
is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. Therefore, the reviewer found that the requested drug is not 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 Pluvicto have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pluvicto, (A9699) once every week for 6 weeks.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that there is no documentation to indicate you require 24/7 rehabilitation 
nursing services. 
 
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. The 
complexity of your nursing medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require rehabilitation nursing for complex 
wound care, parenteral nutrition or tube feedings, tracheostomy management or bowel and bladder 
management. Your medical and rehabilitation needs do not require the intensive interdisciplinary approach 
provided on acute inpatient rehabilitation. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day, five days a week, or 15 hours over seven consecutive days. You have had a functional decline from her 
baseline level of function and would benefit from therapy, but you do not require the intensity of therapy 
provided on acute inpatient rehabilitation. Our physician reviewer found that your condition does not meet 
Medicare criteria for IRF 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that this is medically 
necessary. The Plan denied your request. The Plan says the criteria for a powered pressure-reducing mattress 
have not been met. 
 The Plan follows Medicare rules. Medicare rules say that a powered pressure-reducing air mattress is subject to 
the criteria listed 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 a powered pressure-reducing air 
mattress. Our reviewer says that the requested powered pressure-reducing air mattress is not medically 
necessary. Our physician reviewer found that the provided records do not document that the enrollee currently 
has multiple stage 2 pressure ulcers located on the trunk or pelvis or she has large or multiple stage 3 or 4 
pressure ulcer(s) on the trunk or pelvis or that they have had a myocutaneous flap or skin graft for a pressure 
ulcer on the trunk or pelvis within the past 60 days as required by the relevant LCD. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).