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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure consequent to chronic obstructive pulmonary disease (COPD). The records document that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
titration (AE). Medicare does not cover the home ventilator for this use. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you are appealing the denial of the 
requested home health services. The Plan denied your request. The Plan says that 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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found that the 
documentation supports that the enrollee is expected to benefit from the requested skilled therapy 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 home health services have been met. Therefore, we decided that the Plan has to 
pre-approve home health physical therapy visits.  
 
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 Evenity. 
 
You asked the Plan to pre-approve Evenity. 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 Evenity. Our reviewer says that the 
services are not medically necessary. 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 transcatheter implantation of wireless pulmonary 
artery pressure sensor for long-term hemodynamic monitoring (33289) and an implantable wireless pulmonary 
artery pressure sensor with delivery catheter (C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the device is medically necessary. The 
Plan denied your request. The Plan says because of the lack of literature to support the use of a CardioMEMS 
device and no supporting medical literature that this type of therapy is supported for continued use and benefit 
for the enrollee, this is therefore considered investigational and cannot be approved. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of enrollees with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was implanted, 
reflecting an enrollee population with preserved ejection fraction and was somewhat limited in scope. 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in enrollee management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollees clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter implantation of wireless pulmonary artery pressure sensor for 
long-term hemodynamic monitoring (33289) and an implantable wireless pulmonary artery pressure sensor 
with delivery catheter (C2624).
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. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for an IRF admission. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scalp treatments to be provided by a cosmetologist at a 
barbershop. 
 
You asked the Plan to pre-approve scalp treatments to be provided by a cosmetologist at a barbershop. You say 
that your doctor changed your blood pressure medication and it caused your hair to fall out. You says that you 
are currently receiving services at this barbershop to prevent hair loss and you would like to continue treatment 
to prevent your hair from falling out. The Plan denied your request. The Plan says to receive payment for 
covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The file shows that this barbershop does not participate in the 
Medicare program. Therefore, we decided that the Plan does not have to pre-approve scalp treatments to be 
provided by a cosmetologist at a barbershop.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair options and accessories. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is not 
medically necessary to control power options through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that a cup holder, pouch, and seat lift were requested. We looked at the file and the rules. These 
items do not serve a purpose that is primarily medical in nature. Based on this information, we decided that the 
Medicare rules for coverage have not been met. 
 
The file shows that an expandable control system was requested. 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 requested services. Our physician reviewer found that the enrollee is paraplegic with 
a report of hemiplegia. No information is given on the intact side. The enrollee is able to feed himself. There is 
no evidence that the expandable controller request is medically necessary. 
 
We looked at the physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve wheelchair options and accessories.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a history of osteoporotic fracture or a trial of zoledronic acid before they will approve the 
requested drug. The record indicates that you have age-related osteoporosis without osteoporotic fracture. The 
requested drug is a new start. The provided records do not indicate that you have tried and failed the Plan's 
preferred step-one alternative. The record does not indicate that you have a contraindication to, or would have 
an adverse effect from, the Plan's preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued services. You say that you need more time to get better. The Plan 
denied your request. The Plan says that you no longer require skilled services on a daily inpatient basis. 
 
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 services. Our physician 
reviewer found that records were requested of and received from the contract SNF. The Plan cites notes from 
February 14, 2023, which are not identified in the case file. The Plan argues that the enrollee no longer requires 
SNF care. The Plan noted that SNF records were received for review, but SNF records have not been identified 
by the IRE. As such, the health plan has failed to support its argument. 
 
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 services have been met. The Plan must continue coverage for the 
SNF skilled service until such time as you no longer need 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 continued 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C intravenous immune globulin (IVIG) 
therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that IVIG is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has 
iypogammaglobulinemia in the setting of chemotherapy. The enrollee does not have a primary 
immunodeficiency. The criteria for coverage are not met; therefore, IVIG is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C intravenous immune globulin (IVIG) therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is needed so you can walk again and 
resume your daily activities. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information we have about your condition you do not meet all the requirements. 
 
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 clinical documentation shows that you have active medical co-occurring conditions 
however there are no complex functional impairments specified.  The complexity of your documented nursing, medical needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting IRF services so you can return 
safely to your prior level of function and/or maximum potential. The Plan denied your request. The Plan says 
you do not meet the Medicare criteria for admission to an IRF. Skilled therapies at home or at a skilled nursing 
facility may be approved upon request. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the proprietary clinical laboratory analyses (0312U) and 
immunoassay for analyte other than infectious agent antibody or infectious agent antigen (83516) provided 
August 2, 2022. 
 
You asked the Plan to pay for the Avise CTD testing. You say that please see the attached documents regarding 
the test that was deemed medically necessary by the enrollee's physician. The Plan denied your request. The 
Plan says this service does not meet this requirement of the member's plan of benefits and is excluded from 
coverage. 
 
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 Avise CTD testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the Avise CTD 
testing provided for date of service of August 2, 2022, at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. The provided records include only the laboratory test 
requisition and the test results with no clinical information documenting necessity of the testing or how the 
results will be used for the diagnosis or treatment of the patient's condition or to improve the function of a 
malformed body member as required by the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4. 
 
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 Avise CTD testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the proprietary clinical laboratory analyses (0312U) and immunoassay for analyte 
other than infectious agent antibody or infectious agent antigen (83516) provided August 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided to the enrollee from November 
18, 2021, to November 20, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 280. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented to the hospital with chest pain. Brain natriuretic peptide (BNP) was elevated (no 
baseline shown to compare). The chest x-ray showed interstitial edema, however, she reported a dry cough, 
orthopnea at night unchanged from baseline, denied shortness of breath, lungs were clear on examination, and 
there was no lower extremity edema. Based on the provided documentation, there was insufficient support that 
that patient was experiencing an acute worsening of her baseline CHF to justify the diagnosis code, I50.23. 
Therefore, the DRG 280 is also not supported in the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided to the enrollee from November 18, 2021, to November 20, 2021.