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

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is documentation that the 
enrollee has chronic respiratory failure consequent to chronic obstructive pulmonary disease. Records do not 
document that a BiPAP device (E0471) with average volume assured pressure support (AVAPS) would not 
provide equivalent ventilatory support for the enrollee. As stated in the Local Coverage Determination (LCD): 
Respiratory Assist Devices (L33800): Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pegfilgrastim-CBQV. 
 
You asked the Plan to pre-approve Pegfilgrastim-CBQV. You say that this drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested drug, Pegfilgrastim-CBQV, is not 
medically reasonable and necessary 
 
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 Pegfilgrastim-CBQV. Our reviewer 
says that this drug is not medically reasonable and necessary. Our physician reviewer found that the record 
indicates that the enrollee has a diagnosis of breast cancer and is planned for chemotherapy that has a low risk 
of clinically significant neutropenia. 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 and the provided record does not establish the 
medical necessity of the requested service in the enrollee's specific clinical scenario. The elements of the coverage criteria are not satisfied.s 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 Pegfilgrastim-CBQV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Pegfilgrastim-CBQV.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the neuromonitoring services provided on December 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that these services are 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that intraoperative neurophysiological monitoring (IONM) helps to assess the integrity of neural 
structures and consciousness during surgical procedures, and is considered a standard of care during procedures 
where there is risk of neurological damage. The goal of IONM is to identify intraoperative neural insults to 
allow early intervention to eliminate or to minimize irreversible damage to neurological structures and to 
prevent postoperative neurologic deficits. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the neuromonitoring services provided on December 15, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on November 18, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount. The 
Plan denied your request. The Plan says the cost-sharing amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules).  
 
 
 
 You have been asked to pay a $30 copayment for office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 office visit on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that you are in a lot of pain and need 
the requested injections. The Plan denied your request. The Plan says the injections are not medically necessary 
because the records show the enrollee does not have the absence of untreated radiculopathy or neurogenic 
claudication. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when medically 
necessary and when there is an absence of untreated radiculopathy.  
 
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 facet joint injection services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records show 
that the enrollee has chronic low back pain following a lumbar fusion. The records show that the enrollee's pain 
complain is shooting pain down the legs. The enrollee has had physical therapy, used over-the-counter 
medications, Oxycodone, and ice. Magnetic resonance imaging showed facet arthropathy at multiple levels. 
The enrollee has radicular symptoms and the requested diagnostic medical branch blocks are not medically 
reasonable and 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 facet joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint injection services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper dentures. 
 
You asked the Plan to pre-approve the requested dentures. You say that you are not able to eat. The Plan denied 
your request. The Plan says your benefits have been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The file shows that you last received complete dentures on April 14, 2021. Your plan only covers dentures 
once every 5 years. Based on this information, we decided that the Plans rules for coverage of dentures have 
not been met. Therefore, we decided that the Plan does not have to pre-approve complete upper dentures.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on October 26, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 abdominal ultrasound (76705) provided on October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 27, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
provider did not submit any records for the actual date of service at issue in this case. Records were submitted 
for August 26, 2020 and September 2, 2020. The billed services for August 27, 2020 cannot be verified. 
Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on 
August 27, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta (CPT code J2506). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says there were no contraindications or evidence of intolerance to the preferred 
alternatives Fulphila, Udenyca, Nyvepria. 
  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the cafe file does not contain documentation of trial and failure of Fulphila, Udenyca, or Nyvepria. The 
documentation does not support that Fulphila, Udenyca, or Nyvepria would likely be less effective, and/or 
would likely have adverse effects for the enrollee 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Neulasta (CPT code J2506).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (CPT code J3380). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s): Remicade, 
Inflectra, or infliximab, and Stelara. There is no indication our preferred drug(s) would likely be: less effective, 
and/or cause adverse effects for the enrollee. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Entyvio (CPT code J3380).
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 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 Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing (SN) services. 
 
You asked the Plan to pre-approve continued SN services. You say that because of the enrollee's Alzheimer's 
she is unable to manage her medications. You also say that it is important for the enrollee's health that she has 
assistance with her medications. The Plan denied your request. The Plan says the enrollee does not meet the 
Guidelines for the requested SN services which do not appear 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 continued SN services. Our reviewer 
says that continued SN services are not medically reasonable and necessary. Our physician reviewer found 
there is no documentation that continued skilled nursing services are required to effectively provide treatment, 
care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program 
to maintain the patient's condition and/or prevent deterioration. Our reviewer found that the provided records 
do not document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate any further skilled nursing visits beyond what have already been approved. Our physician reviewer 
also found that there are no medical notes from the patients treating physician are provided documenting an 
order or need for additional skilled nursing 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 continued SN services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing (SN) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (CPT code J7323). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says six months have not elapsed since your previous injection on June 22, 2022. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Review of the file shows that six 
months have not elapsed since your previous injection on June 22, 2022. Therefore, we decided that the Plan 
does not have to pre-approve Euflexxa (CPT code J7323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp 10MCG/0.4ML syringe. 
 
You asked the Plan to pre-approve the medication. You say that the initial request was denied due to primary 
diagnosis listed as anemia from blood loss. You state the enrollee's anemia stems from NASH Cirrhosis 
(K75.81) and renal disease (CKD Stage 3). You state the enrollee is currently dependent on blood transfusions 
as well as iron infusions to help keep blood and iron stores at a sustainable level. The Plan denied your request. 
The Plan says treatment of Anemia in Chronic Kidney Disease requires patients on dialysis to have adequate 
iron stores as indicated by serum ferritin level more than or equal to 100mcg/L or serum transferrin saturation 
more than or equal to 20% within the last three (3) months. The Plan states the information provided to us 
indicates that this enrollee's ferritin levels are below this requirement. 
 
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 the medication. Our physician reviewer 
found the review has determined that the documentation does not support that the Aranesp 10MCG/0.4ML 
syringe is medically reasonable and necessary for the enrollee. The documentation does not support that the 
Aranesp 10MCG/0.4ML syringe 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp 10MCG/0.4ML syringe.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (CPT code J7318). 
 
You asked the Plan to pre-approve the medication. You say that you are requesting a fourth hyaluronic 
injection for treatment of shoulder osteoarthritis. The Plan denied your request. The Plan says the enrollee does 
not meet criteria. The Plan states the enrollee has already received two (2) separate series of hyaluronic injections for treatment. The Plan states the FDA approved use, hyalurons have been recognized as a 
therapeutic option in osteoarthritis of the shoulder; however, repeat injections for shoulder arthritis are limited 
to a single repeat course. 
 
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 the medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of osteoarthritis of the shoulder. The record 
indicates that the enrollee has received three injections previously at intervals of greater than six months. The 
most recent injection is less than six months ago in February 2022. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
medical record provided is insufficient to support the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service at this time. 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Durolane (CPT code J7318).