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

We decided that the Plan has to pre-approve Lumizyne.
You asked the Plan to pre-approve these services. You say that Nexviazyme is contraindicated. The Plan
denied your request. The Plan says that the step therapy requirement is not 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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of Pompe
disease. The provider states that Nexviazyme is contraindicated due to the enrollee's complex medical history
and specifically, his diagnosis of diabetes. Although the enrollee has not tried and failed the Plan's required
drug, Nexviazyme, the records show that the required drug would be potentially less effective for the enrollee
and would likely have adverse effects. The provider notes that the enrollee would require at least 500mL of
D5W with each infusion which would only complicate his diabetes control. Therefore, Lumizyme is reasonable
and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Lumizyne.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc for the enrollee.
You asked the Plan to pre-approve the drug. You say that the enrollee has bilateral osteoarthritis and instability,
is a fall risk, has ataxia, is in severe pain, and is unable to walk upstairs. The Plan denied your request. The
Plan says the enrollee has not tried one of the alternative 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 drug. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found the plan requires a
trial of Monovisc, Synvisc, or Orthovisc before they will approve the requested drug. In this case, the enrollee
has not tried and failed the required drugs. There is no documentation provided indicating that the plan's
required drugs 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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Genvisc for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the abdomen and
pelvis for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the doctor did not submit clinical notes showing medical history, physical examination,
or other relevant information.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found the only clinical info
included was "flank pain." There is no other info including urinalysis or physical exam or differential
diagnosis. Absent any clinical data, the medical necessity for this scan cannot be established.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve computed tomography (CT) scan of the abdomen and pelvis for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request.
The Plan says a review of the current medical literature indicates that this service is considered experimental and
investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally
recognized peer-reviewed medical literature published in the English language.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not
covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if
the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are
not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental.
More research is needed to show safety and efficacy.
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the
Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the ConfirmMDx epigenetic assay for prostate cancer provided to the
enrollee on June 14, 2021.
You asked the Plan to pay for the services. You say that the service should be covered based on Medicare
guidelines.
The Plan denied your request. The Plan says that this testing is not recommended to be done at the same time
as the biopsy.
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically
necessary. Therefore, we decided that the Plan has to pay for the ConfirmMDx epigenetic assay for prostate
cancer provided to the enrollee on June 14, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Fentanyl patch for the enrollee.
You asked the Plan to pre-approve the patch. You say that this is medically necessary. The Plan denied your
request. The Plan says this is denied as a benefit exclusion.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Fentanyl patch for the
enrollee
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 this is medically necessary. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.
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 you are medically stable and do not meet the coverage criteria for an IRF admission. With your current medical stability, and no other medical complexity, there is no need for physician supervision three times per week (at a minimum) for the ongoing management for any active or acute exacerbations of chronic medical conditions. There are no acute rehabilitation nursing needs. At your current functional level, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. Medical needs can be safely met in an alternate and low intensity setting such as in an SNF with therapies as provided currently.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit, X-Rays, and chiropractic manipulative
treatment provided on August 26, 2021.
You asked the Plan to pay for office visit, X-Rays, and chiropractic manipulative treatment. You say that your
provider is performing manual manipulation of the spine to correct subluxation. The Plan denied your request.
The Plan says the denial of payment for these services is correct, because an office visit and X-Rays are not
covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that you must pay $20
copayment for the covered chiropractic manipulative treatment.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. 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 $20 copayment for each covered chiropractic visit.
The records show that the office visit and X-Rays at issue are not manual manipulation of the spine; therefore,
they are not covered by Medicare or the Plan when performed by a chiropractor. You have also been asked to
pay $20 copayment for the covered chiropractic manipulative treatment. This copayment is a contractual
obligation you agreed to when you enrolled in the Plan. Therefore, we decided that the Plan does not have to
pay for an office visit, X-Rays, and chiropractic manipulative treatment provided on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services billed with DRG 853 provided April
10, 2020 to May 22, 2020.
You asked the Plan to pay for the inpatient services billed with DRG 853. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by
the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with A41.9 defined as Sepsis, unspecified organism. 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 inpatient services billed with DRG 853.
Our reviewer says that the documentation does not support that the DRG billed. Our physician reviewer found
the acute care hospital course was complicated by sepsis, respiratory failure and acute kidney failure requiring
initiation of hemodialysis. The enrollee was accepted to the long-term acute care (LTAC) facility for post-acute
care, including hemodialysis, oral Vancomycin, nutritional support, rehabilitation services and dementia
management. The enrollee was afebrile, with stable vital signs during the LTAC hospital course, and
completed course of oral antibiotics. While the enrollee may have experienced sepsis during the preceding
acute care inpatient hospitalization, she was not experiencing on-going sepsis at the time of admission to, or
over the course of, the LTAC facility encounter. The enrollee was continued on oral Vancomycin for
Clostridium difficile, without need for intravenous antibiotics. The enrollee was clinically stable during the
course of the long-term acute care admission. The documentation shows that DRG 853 was not supported by
the documentation. The principal diagnosis A41.9 was not supported by the documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient services billed with DRG 853 provided April 10, 2020 to May 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on March
28, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this
copayment. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $225 copayment for ambulance services.
The enrollee has been asked to pay a $225 copayment for the ambulance services. This means that the enrollee
has been asked to pay the correct amount based on the contract with the Plan.
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore,
we decided that the Plan does not have to waive the copayment for the ambulance services provided on March
28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided April 24, 2021 to May 6,
2021 billed with DRG 682.
You asked the Plan to pay for the inpatient services billed with DRG 682. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with N17.9, acute kidney failure, unspecified. 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 inpatient services billed with DRG 682. Our reviewer
says that the documentation does not support the DRG billed. Our physician reviewer found the enrollee
presents to the emergency department with complaints of some bruising of the left lower extremity with
swelling. Admitting physician noted acute on chronic renal failure enrollee's creatinine baseline with 0.8 noted
to be 2.1 in the emergency department. While the enrollee presentation warranted consideration of acute kidney
failure as a diagnosis, there was no evidence of increase in baseline serum creatinine as documented by the
physician by 3.0 times baseline. Laboratory results in the medical record revealed highest recorded serum
creatinine as 2. The documentation shows that DRG 682 is not supported by the documentation. The principal
diagnosis code assignment of N17.9, acute kidney failure, unspecified is not supported by the documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient services provided April 24, 2021 to May 6, 2021 billed with DRG 682
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hepatectomy (47120) provided on December 14, 2020.
You asked the Plan to pay for the hepatectomy. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support
the service 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.
In this case, the CPT Code Manual definition of code 47120 is hepatectomy, resection of liver; partial
lobectomy.
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 hepatectomy. Our reviewer says that CPT code 47120
does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does
not describe a surgical resection of the liver. Unable to cite operative report, as this procedure is not
documented.
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 hepatectomy have not been met. Therefore, we decided that the Plan does
not have to pay for the hepatectomy (47120) provided on December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered on July 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is 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 pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee had an assessment of
melanoma of the right frontotemporal scalp. A shave biopsy on June 17, 2021 showed compound melanocytic
proliferation with unusual features. The submitted documentation does not contain documentation of Stage T1b
disease, or of concern about the adequacy of microstaging. The DecisionDx-Melanoma testing was 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 pay for the DecisionDx-Melanoma testing rendered on July 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right
shoulder.
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 MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has right shoulder pain.
There is no record that she had contact with the provider after a recent (within three months) six month trial of
treatment that failed to improve symptoms. There is no documentation of supportive treatments, including
medications for swelling or pain, phyical therapy, and/or oral or injected steroids. The MRI is 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 magnetic resonance imaging (MRI) of the right shoulder.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for podiatry visits you had on July 15, 2021, and
August 5, 2021.
You asked the Plan to reduce the copayments for the podiatry visits. You say that the office told you that your copayment
was only $20. The Plan denied your request. The Plan says you were charged these copayments 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 $45 copayment
for podiatry visits.
You have been asked to pay a $45 copayment for the podiatry visits. 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 reduce the copayments for podiatry visits
you had on July 15, 2021, and August 5, 2021.