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

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this device is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the spinal 
cord stimulator trial have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria for coverage of a spinal cord stimulator 
are 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 spinal cord stimulator trial. Our reviewer says that the requested device is not medically reasonable and necessary. Our physician reviewer 
found This 62-year-old gentleman has widespread pain. Magnetic resonance imaging (MRI) scan of his back 
shows facet arthropathy and degenerative changes. of significance is his past history of Bipolar I disorder and 
currently taking six different psychotropic medications. The notes indicate "multiple psychiatric 
hospitalizations throughout his adulthood due to elevated psychiatric symptoms." In this case, the patient does 
not have an evidence-based indication for a spinal cord stimulator trial. The request is not medically reasonable 
or 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 a spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
  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 Prolia. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and Prolia cannot be recommended. Our physician reviewer 
found the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a 
new start. Our reviewer found that the provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step one alternative, Zoledronic acid. Our physician reviewer also found that the record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a cervical epidural steroid injection (ESI). 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ESI 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 pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has chronic neck pain. 
Magnetic resonance imaging (MRI) showed narrowing of the spinal canal at the C4 to C5 level with multiple 
level degenerative findings. He reports pain at the cervical thoracic junction and neck pain radiating to the back 
of the head. The ESI is reasonable and medically necessary due to documented cervical spinal stenosis with 
radicular pain in the C3, C4, and C5 distribution. 
 
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 a cervical epidural steroid injection (ESI).  
 
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 subsequent nursing facility care (99308) provided on 
October 6, 2021. 
 
  You asked the Plan to pay for subsequent nursing facility care (99308). You say that the enrollee provided 
incorrect patient information and you were informed they were eligible for coverage. You say that the claim 
was billed within the timely statute and should be reconsidered. 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 subsequent nursing facility care (99308) provided on October 
6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
device and related supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that the requested 
items/services are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage 
for CGMs and related supplies have not been met. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) device and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral transforaminal epidural steroid injections of 
L4-5 and L5-S1 (64483, 64484). 
 
You asked the Plan to pre-approve the injection procedure. You say that please see attached documentation. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria  
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 injection procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The NCD and LCD require imaging support the diagnosis and the planned procedure. 
That is not the case here. The request is considered not medically reasonable or 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 the injection procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral transforaminal epidural steroid injections of L4-5 and L5-S1 (64483, 
64484).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria 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 Ilumya. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the 
enrollee has plaque psoriasis. The requested medication is a new start. The provided records do not indicate 
that the enrollee has tried and failed the Plans preferred step one alternative. The record does not indicate that 
the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided by an out-of-network provider on 
July 14, 2021. 
 
You asked the Plan to pay for cataract surgery. You say that the doctor's medical records should be reviewed to 
confirm medical necessity of the rendered services. The Plan denied your request. The Plan says out-of-
network care was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for cataract surgery provided by an out-of-network 
provider on July 14, 2021.
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 you need LTACH care. The Plan denied 
your request. The Plan says you do not meet criteria for an LTACH admission. 
 
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 that you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 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 Keytruda. Our reviewer says that the 
requested drug, Keytruda, is not medically reasonable and necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of recurrent metastatic non-small cell lung cancer of unknown PDL-1 
expression level.  The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer 
journals were submitted for review. The elements of the coverage criteria are not satisfied.  The requested 
service cannot be recommended  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services 
 
You asked the Plan to pre-approve SNF services. You say that the patient meets inpatient rehabilitation facility 
criteria as per the center of Medicare and Medicaid services (CMS) guidelines with a diagnosis of seizures, 
respiratory failure, and other medical issues; and the patient can tolerate 3 hours of daily therapy and would 
greatly benefit from said therapy. You also say that the patient has a community discharge with the support of 
her brother, and also requires physical and occupation therapy services due to decline in mobility. You also say that the patient requires 24-hour nursing to provide the supervision of her medical issues, and the patient has 
the complexity of care that requires specialists in pulmonary care, orthopedics and neurology. The Plan denied 
your request. The Plan says based upon the information received, the member does not have the complexity of 
rehabilitation, medical management, nursing needs, and does not meet the CMS 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 services. Our reviewer says that 
this does not meet criteria Our physician reviewer found the enrollee does not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance (eg, proton) imaging (MRI), brain 
(including brain stem); without contrast material, followed by contrast material(s) and further sequences 
(70553). 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation 
 
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 the MRI. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found routine imaging is 
not indicated in the absence of a clinical suspicion. There are no neurological complaints to just this imaging of 
the brain. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance (eg, proton) imaging (MRI), brain (including brain stem); without contrast 
material, followed by contrast material(s) and further sequences (70553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet block injections. 
 
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 facet blocks 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has diagnoses of post-
traumatic lumbar facet syndrome, lumbar radiculopathy, and myofascial pain syndrome. Magnetic resonance 
imaging (MRI) of the lumbar spine in September of 2020 revealed development of severe central spinal 
stenosis, foraminal stenosis, and ligamentum flavum hypertrophy. The other pain generators have not been 
addressed in the submitted documentation. Facet disorders are a diagnosis of exclusion and the enrollee has 
multiple other pain generators present. The criteria for coverage are not met and the services are not reasonable 
or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet block injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting care for the enrollee 
at an LTACH. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 enrollee is receiving appropriate care at the present acute care hospital. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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. We also found that 
CPT code 83789 was billed for specimen validity testing. Validity testing on urine specimens used for drug 
testing shall not be separately billed. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on December 2, 2021.