Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drug. There is no documentation provided indicating that the the plans 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prescription custom fabricated foot insert, each, 
removable (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that your primary doctor referred you to an 
orthopedic doctor because of pain in your arches. You called the Plan and asked if you were covered for 
orthotics and was told that the Plan will pay 100% of your orthotics. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the prescription custom fabricated 
foot insert, each, removable (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma (PRP) injection (0232T). 
 
You asked the Plan to pre-approve PRP injection. You say that the PRP injections would help you medically 
and help with the pain in your knees. You say that your doctor advised it would work to alleviate your pain and 
help you overall. The Plan denied your request. The Plan says the requested PRP injections 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 PRP injection. Our reviewer says that 
the requested PRP injection is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a limited amount of high-quality evidence to support its effectiveness to support its 
regular use in treating ankle osteoarthritis. Therefore, the reviewer found that the request for PRP injection 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 PRP injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet rich plasma (PRP) injection (0232T).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that your home exercise program is a series of 
exercises that you complete 3-4 times a week, with that your therapist will work in a particular area on a 
specific muscle to help loosen it up and you cannot do it by yourself. You say that you still need physical 
therapy. The Plan denied your request. The Plan says an additional 4 physical therapy visits are not medically 
necessary. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. You have no recent injury or a decline in function. The 
additional therapy services are not appropriate duration and frequency for treatment of your medical condition 
and therefore are 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 4 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator, rental (Inogen 5). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the enrollee desaturates 
during physical therapy sessions and wanted to try switching to the G5 unit because it can provide a max pulse 
flow setting of 5L. The Plan denied your request. The Plan says the Plan is currently providing the enrollee 
with the most appropriate equipment that meets their needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a portable oxygen concentrator (ActiVox). The portable oxygen concentrator 
(ActiVox) serves the same purpose as portable oxygen concentrator. Therefore, we decided that the Plan does 
not have to pre-approve the portable oxygen concentrator, rental (Inogen 5).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec. 
 
You asked the Plan to pre-approve Nurtec. You say that this should be approved. The Plan denied your request. 
The Plan says the requested drug is not covered under Medicare Part B. 
 
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 Nurtec.  
 
Benefits for Nurtec may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rosuvastatin. 
 
You asked the Plan to pre-approve Rosuvastatin. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Rosuvastatin.  
 
Benefits for Rosuvastatin 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: ER
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the emergency department visit received on September 
7, 2022, minus any cost share requirement. 
 
You asked the Plan to hold you harmless for the emergency department visit. You say that you were in custody 
and never consented to treatment. The Plan denied your request. The Plan says that the coding is not supported. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the emergency department visit by a contract provider. The file does not show that the Plan 
provided notice that the emergency department visit would not be covered. Under Medicare rules, this means 
the emergency department visit is considered approved by the Plan. Therefore, we decided that the Plan has to 
hold you harmless for the emergency department visit received on September 7, 2022, minus any cost share 
requirement.  
 
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 Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the requested Feraheme is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first. 
 
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 Feraheme. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has iron deficiency anemia. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on March 7, 2022. 
 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes.  
 
We looked at the file and Medicare rules. Billed procedure code 99152 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 00732 provided on February 2, 
2022. 
 
You asked the Plan to pay for the anesthesia services coded 00732. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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 00732 is anesthesia for upper gastrointestinal endoscopic 
procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography 
(ERCP). 
 
We find that CPT code 00732 is not supported in the medical record. Specifically, this service was billed with 
place of service 22 (On Campus-Outpatient Hospital). However, the enrollee was registered as an inpatient of a 
hospital. This means the place of service billed is incorrect and this claim is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services coded 00732 have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00732 provided 
on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022, billed with 
codes 81220, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 81283, 81291, 81306, 81335, 
81350, 81355, 81381 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 27, 2022, billed with codes 81220, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 
81283, 81291, 81306, 81335, 81350, 81355, 81381 and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with 
or without adjustability (L5848), an addition, endoskeletal system, above knee or hip disarticulation, knee 
extension assist (L5850), an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature (L5856), an addition to lower limb prosthesis, multiaxial ankle with swing 
phase active dorsiflexion feature (L5968) and an all lower extremity prostheses, flex-walk system (L5981). 
 
 
 You asked the Plan to pre-approve prosthetics. You say that the enrollee was an active community ambulator 
prior to amputation and is expected to resume all pre-amputation activities upon receipt of his prosthesis. The 
Plan denied your request. The Plan says the enrollee's physician documents K3 potential. The document notes 
do not show why a mechanical K3 knee will not meet the enrollee's needs. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found an addendum was added to the medical records on 11/21/2022 after the health plan's initial 
denial of the K3 microprocessor knee on 10/04/2022 arguing necessity of the K3 microprocessor knee. The 
contemporaneous medical records do not document necessity of the K3 microprocessor knee as opposed to a 
K3 mechanical knee as required by the LCD and Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature (L5845), an addition to 
endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability 
(L5848), an addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), an 
addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature (L5856), 
an addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and 
an all lower extremity prostheses, flex-walk system (L5981).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested provider. You say that 
the physician's services are medically necessary. The Plan denied your request. The Plan says the requested 
physician's services at a tertiary level of care are not 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 the physician's services. Our reviewer 
says that the requested physician's services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that in this case, the record indicates that you have post nasal drip and tinnitus.   
The record provided is insufficient to establish the medical necessity of the requested service. You can be seen 
by the Plan identified provider. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physician's services to be provided by the requested provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the 
requested provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve omalizumab (J2357). 
 
You asked the Plan to pre-approve omalizumab. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested use of omalizumab is not approved by the 
FDA. 
 
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 omalizumab. Our reviewer says that the 
requested drug, omalizumab, is not medically necessary. Our physician reviewer found the requested use of 
omalizumab is not Food and Drug Administration-approved for the enrollee's diagnosis. The also reviewer 
found that he use of omalizumab for treatment of of 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 use of omalizumab 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 omalizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve omalizumab (J2357).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no record of psychological clearance. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not have an evidence-based indication for a spinal cord stimulator trail. There has 
not been prior cervical spine surgery. There are several other options available. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro. 
 
You asked the Plan to pre-approve Neulasta Onpro. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 Neulasta Onpro. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found carboplatin is not high risk for 
neutropenic fever and did not have on prior monotherapy. The use of the requested drug is 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 Neulasta Onpro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Neulasta Onpro.