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 this is medically necessary. The Plan denied your 
request. The Plan says that you have no trial and failure with any biologic drugs for the treatment of psoriasis. 
 
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 Ilumya 
is not medically reasonable and necessary. The Plan requires a trial of 2 of the following: Humira, Rinvoq, 
Skyrizi, Actemra (subcutaneous), Cosentyx, Otezla, Xeljanz or Xeljancz XR, Orencia (subcutaneous), and 
Enbrel before they will approve the requested drug. In this case, you have 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 you. Our physician reviewer found that your condition does not 
meet step therapy criteria for Ilumya. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hematology profile provided on March 9, 2021. 
 
You asked the Plan to pay for the hematology profile. You say that the hematology profile provided on March 
9, 2021, was medically necessary. The Plan denied your request. The Plan says the hematology profile 
provided on March 9, 2021, was 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 pay for the hematology profile. Our reviewer says 
that the hematology profile provided on March 9, 2021, was not medically necessary. Our physician reviewer 
found the record indicates that the enrollee has essential thrombocytopenia in February 2021. The record provided does not indicate the medical necessity of a hematology profile in the enrollee's specific clinical 
scenario or how the result would have altered diagnosis and management. 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.  The requested service is not 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 the hematology profile have not been met. Therefore, we decided that the Plan 
does not have to pay for the hematology profile provided on March 9, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
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 care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do have documented skilled therapy needs. Daily skilled services are reasonably required to 
establish a maintenance program and/or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. You are walking household 
distances with a rolling walker with contact guard assistance or supervision and is modified independent for 
transfers. Provided records do not document a significant decline in your functional status to necessitate daily 
inpatient skilled therapy services. You do not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time 
basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 18, 2021, through 
June 21, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an 
inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from June 18, 2021, through June 21, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that this device is medically 
reasonable for your condition. The Plan denied your request. The Plan says the criteria for therapeutic CGMs 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a therapeutic continuous glucose monitor (CGM) and supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs or documented skilled therapy needs. Daily skilled services are not shown to 
be required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cardiomyopathy Risk Panel provided on December 31, 
2020. 
 
You asked the Plan to pay for the Cardiomyopathy Risk Panel. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this testing is not covered for 
screening purposes. 
 
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, the Cardiomyopathy Risk Panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted 
does not include any clinical information to verify why this testing was ordered or how the results will effect 
the member's treatment. Therefore, we decided that the Plan does not have to pay for the Cardiomyopathy Risk 
Panel provided on December 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips. 
 
You asked the Plan to pre-approve Accu-Chek Aviva Plus test strips. You say that this is medically necessary. 
The Plan denied your request. The Plan says that you do not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of test strips. Without this, medical necessity cannot be 
established. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test 
strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology testing provided on September 29, 2021. 
 You asked the Plan to pay for the services provided. You say that the codes are billable and payable. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due. 
 
We looked at the file and Medicare rules. The claim shows the testing was ordered without complaint, or a 
suspected or reported diagnosis. There are insufficient medical records to show the purpose of the testing.  
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pathology testing provided on September 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services (75726-26-59, 75774-26-59) provided 
on June 30, 2021. 
 
You asked the Plan to pay for angiography services. You say that this is supported in the records. The Plan 
denied your request. The Plan says these services are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
 
 
 
 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 angiography services Our reviewer says that 
these codes are not supported. Our physician reviewer found vascular embolization procedures include 
associated radiological supervision and interpretation, intra-procedural guidance, road-mapping, and imaging 
necessary to document completion of the procedure. The records do not support that 3 units of 75726 and 4 
units of 75774 were distinct procedural services from the other billed services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of angiography services have not been met. Therefore, we decided that the Plan 
does not have to pay for angiography services (75726-26-59, 75774-26-59) provided on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis and 
lower spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is appropriate and medically necessary. The Plan 
denied your request. The Plan says this is 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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found you had an extensive 
workup in October 2021. There is a history of BRCA genetic variant, and a history of breast cancer. You also 
have had a cardiac transplant. The prior MRI of the entire spine revealed no bone destruction. There was noted 
grade 2 sponylolisthesis L5-S1. A normal electromyography was done as well. It should be noted that the 
consultant spine fellow mentioned MR neurography of the lumbosacral plexus which was not done. There are 
no updated notes since October, 2021 to explain the reason for a repeat MRI of the lumbar spine and also an 
exam of the pelvis. MR neurography was mentioned in October, 2021 but no order has been processed and 
there has been no discussion concerning further workup after the October 2021 notes. Absent such notes and 
detailed discussion by the requesting physician the medical necessity for repeat MRI of the lumbar spine and a 
new MRI of the pelvis has not been 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the pelvis and lower spine.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronary calcium score test by computed tomography 
(CT) (75571). 
 
You asked the Plan to pre-approve the screening test. You say that you were authorized by your referring 
primary care physician. The Plan denied your request. The Plan says coronary calcium score test by CT is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the screening test have not been met. Therefore, we decided that the Plan does not have to pre-
approve a coronary calcium score test by computed tomography (CT) (75571).
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 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 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 while you may benefit from physical therapy and occupational therapy, your 
rehabilitation can be safely provided at a lower intensity and alternate setting such as a skilled nursing facility or in-home with services. Documentation does not support the necessity for admission to an IRF. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport, level 1 (A0427) and ground mileage (A0425) provided August 6, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance service should be separately 
billed. The Plan denied your request. The Plan says the transportation is not separately billable. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. Medicare rules 
say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary to another 
hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the 
original provider. This movement of the patient is considered "patient transportation" and is covered as an 
inpatient hospital service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record shows that the enrollee was 
admitted as inpatient to the origin location provider. The record did not include adequate documentation 
showing that the enrollee was discharged from the original provider when transported to another provider. This 
means that the ambulance service appears to be covered as an inpatient hospital service and is not separately billable. Therefore, we decided that the Plan does not have to pay for the ambulance service, advanced life 
support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided August 6, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve extended-release triamcinolone acetonide injectable suspension 
(Zilretta). 
 
You asked the Plan to pre-approve Zilretta. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that extended-release triamcinolone acetonide injectable 
suspension (Zilretta) not medically necessary because it has not demonstrated a significant improvement in 
osteoarthritis pain compared with the immediate-release formulation of triamcinolone acetonide. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that Zilretta 
is not medically necessary. Our physician reviewer found the provided documentation supports that the Zilretta 
is medically reasonable and necessary for the enrollee. The documentation supports that the Zilretta is safe and 
effective 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
extended-release triamcinolone acetonide injectable suspension (Zilretta).  
 
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.