Persius/hicric huggingface dataset:
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 the enrollee has moderate to severe plaque psoriasis all 
over their body, and has tried and failed a topical cream and scalp oil. You also say that the enrollee is not a 
candidate for the mentioned medications required by the Plan to be used. The Plan denied your request. The 
Plan says this request does not meet the Plan's Part B step therapy criteria for Ilumya. 
 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 
enrollee does not meed the criteria for coverage for Ilumya. Our physician reviewer found there is no indication 
that the enrollee has tried and failed the required drugs. Our reviewer also found that there is no indication 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine and administration provided on 
May 17, 2021. 
 
You asked the Plan to pay for the Zoster (shingles) vaccine and administration. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster (shingles) 
vaccine and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Zoster 
(shingles) vaccine and administration. Therefore, we decided that the Plan does not have to pay for the Zoster 
(shingles) vaccine and administration provided on May 17, 2021.  
 
Benefits for the Zoster (shingles) vaccine and administration 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 Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested Evenity is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail ONE formulary Oral Bisphosphante 
AND ONE formulary injectable alternative: zoledronic acid, pamidronate OR there is clinical documentation 
stating Oral AND Injectable formulary alternatives are contraindicated. 
 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 Evenity. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex device is experimental. More research is needed. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2022, to 
February 5, 2022. 
 
You asked the Plan to pay for the home health services. You say that the NOA was submitted. The Plan denied 
your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on both the claim at 
issue and the NOA was not billed with an admission date in 2022. Based on this information, we find that the 
Medicare rules for payment have not been met. Therefore, we decided that the Plan does not have to pay for the 
home health services provided from January 7, 2022, to February 5, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the dermatology office visit provided on May 26, 2022. 
 
You asked the Plan to pay for the dermatology visit. You say that the records support this was a medically 
necessary service. The Plan denied your request. The Plan says that another dermatologist at the same group 
practice was already paid for an evaluation and management service on the date in question. There is no 
evidence showing that these two visits were for unrelated conditions. 
 
The Plan must follow Medicare rules. Medicare rules say that for physicians on the same specialty in the same 
group practice who both see a patient on the same date of service, only one evaluation and management service 
may be reported unless the evaluation and management services are for unrelated problems. 
 
We looked at the file and Medicare rules. The claim shows that different diagnosis codes were reported for the 
two visits. In addition, the visit note at issue clearly indicates that the physician on the paid claim was treating 
the enrollee for follow-up of a biopsy, while this claim was for follow-up after Mohs surgery. As there is 
evidence that these two providers were treating unrelated problems, we find that the criteria for coverage of this 
office visit have been met. Therefore, we decided that the Plan has to pay for the dermatology office visit 
provided on May 26, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73501 for services provided on June 13, 
2022. 
 
You asked the Plan to pay for procedure code 73501. 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 73501 is radiologic examination, hip, unilateral, with 
pelvis when performed; 1 view. 
 
We find that CPT code 73501 is not supported in the medical record. Specifically, this code was billed with 
modifier RT (right side). This code was billed with a diagnosis of T84.021D (Dislocation of internal left hip 
prosthesis [subsequent encounter]). It is not appropriate to report a diagnosis code for the left side when the 
procedure modifier for the right side was billed on the claim line. Based on this information, we decided that 
Medicare rules for coverage of procedure code 73501 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 73501 for services provided on June 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro and Velcade. 
 
You asked the Plan to pre-approve Darzalex Faspro and Velcade. 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 Darzalex Faspro and Velcade. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the requested use of 
Darzalex Faspro and Velcade is not FDA-approved for the enrollees diagnosis. The requested use 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 Darzalex Faspro and Velcade have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Darzalex Faspro and Velcade.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement coded 77002 
provided on July 27, 2022. 
 
You asked the Plan to pay for the fluoroscopic guidance for needle placement. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says this code is not separately payable. 
 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, we have confirmed that code the 
fluoroscopic guidance for needle placement is an add-on code and has not been billed with an appropriate 
primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement coded 77002 
provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for IV therapy provided on June 2, 2022, to 
June 21, 2022. 
 
You asked the Plan to waive the copayment for IV therapy. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay $250 
copayment for physician/practitioner services, including doctors office visits.  
 
You have been asked to pay $250 copayment for IV therapy. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 IV therapy provided on June 2, 2022, to June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the requested wheelchair is medically 
necessary. The Plan denied your request. The Plan says the enrollee is a limited household ambulator with the 
upright walker and she can propel a manual wheelchair in the home. does not meet requirements for the power 
mobility device. The documentation submitted does not include a physician office note with face-to-face 
examination with documentation to support the member's mobility limitation that impairs the ability to 
complete toileting, dressing, bathing, feeding or grooming in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 The file shows that the enrollee does not have a mobility deficit that impairs her participation in MRADLs, and 
her condition can be improved by a walker, cane, or manual wheelchair. The documentation submitted does not 
include a physician office note with a face-to-face examination to support the enrollees mobility limitation. 
This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and 
including 300 pounds (K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy of varicose veins, 1 extremity; 10-20 
stab incisions (CPT code 37765), injection of sclerosant; multiple incompetent veins (other than telangiectasia), 
same leg (36471) and endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of 
a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and 
monitoring, percutaneous; first vein treated (36482). 
 You asked the Plan to pre-approve the services. You say that the enrollee has had significant leg pain that has 
kept them up at night. You state the enrollee has a difficult time performing his daily activities. The Plan 
denied your request. The Plan says the endovenous ablation of the GSV should be performed first followed by 
six weeks of conservative treatment before the smaller veins should be addressed. The enrollee also still has 
saphenous reflux that has not been eliminated. 
 
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 physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical necessity of the 
treatments in question. 
 
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 stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions (CPT code 37765), 
injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg (36471) and 
endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive 
(eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, 
percutaneous; first vein treated (36482).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of home health aide (HHA) services 
per week. 
 
You asked the Plan to pre-approve additional hours per week of HHA services. The Plan denied your request. 
The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional hours per week of HHA 
services. Our reviewer says that additional hours per week of HHA services are not medically reasonable and 
necessary. Our physician reviewer found you have impaired mobility as well as ability to perform transfers and 
daily activities. A time for task tool assessing activities of daily living was performed on September 1, 2022, 
and assessed your level of function with regards to mobility, transfers and performing and daily activities. It 
indicated that you require a total of 39 hours per week for bathing, feeding, transfers, ambulation, toileting, 
incontinence management, medication assistance, meal preparation, laundry, and housekeeping. Our reviewer 
found that this appears reasonable given your medical conditions and level of function. Our physician reviewer 
also found that the additional 31 hours of HHA services 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 additional hours per week of HHA services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional hours of home health aide (HHA) services per 
week.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 2, 2022 to 
March 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 2, 2022 to 
March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service April 13, 
2022. 
 You asked the Plan to pay for procedure code(s) 88305. You say that you disagree with the denial. The Plan 
denied your request. The Plan says this code is included in the skilled nursing facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 88305 has a Professional/Technical indicator of 1. This means that CPT code 88305 has 
both a professional and technical component. In this case, CPT code 88305 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 88305 billed for date of service April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation with written report rendered 
on July 13, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The file 
shows that the services were not performed in the inpatient setting. Therefore, we decided that the Plan does 
not have to pay for the blood smear interpretation with written report rendered on July 13, 2022.