Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cooled radiofrequency ablation (RFA) to the lumbar 
spine. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says non-thermal modalities for facet joint denervation including chemical, low-grade 
thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation are considered not reasonable 
and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that non-thermal modalities for facet joint 
denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and 
cryoablation are not covered. 
 
The requested pain management procedure is statutorily not covered at this time, as it is a non-thermal 
modality. 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 cooled radiofrequency ablation (RFA) to 
the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek smartview strips. 
 
You asked the Plan to pre-approve Accu-Chek smartview strips. 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. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Specifically, medical records were not provided. Without this 
documentation, medical necessity is not able to be established. Based on this information, we decided that 
Medicare rules for coverage of Accu-Chek smartview strips have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Accu-Chek smartview strips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Padcev/Enfortumab, Keytruda, and Dexamethasone. 
 
You asked the Plan to pre-approve Padcev/Enfortumab, Keytruda, and Dexamethasone. 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 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 Padcev/Enfortumab, Keytruda, and 
Dexamethasone. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
the drug combination is not FDA approved, supported by the NCCN guidelines, major drug compendia, or 
phase III clinical trials. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Padcev/Enfortumab, Keytruda, and Dexamethasone have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Padcev/Enfortumab, Keytruda, and 
Dexamethasone.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization denied because the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care, such as a skilled nursing facility (SNF). 
 
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 enrollee's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need 
for physical and/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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, G0151, G0300, Q5001) 
provided October 29, 2021 to November 18, 2021. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes G0299, G0151, G0300, & Q5001 are not supported in the medical record. Specifically, 
the plan of care in the provided records was signed on December 8, 2021, after the claim was already 
submitted. Based on this information, we decided that Medicare rules for coverage of the home health services 
have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0299, 
G0151, G0300, Q5001) provided October 29, 2021 to November 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy and Nivolumab. 
 
You asked the Plan to pre-approve Yervoy and Nivolumab. 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 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 Yervoy and Nivolumab. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the combination of Yervoy 
and Nivolumab is not FDA approved for the treatment of metastatic cervical cancer. Use is not supported by 
major drug compendia or the medical literature for off-label use. The service 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 Yervoy and Nivolumab have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy and Nivolumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (43644 and 43281) provided from 
September 15, 2021, to September 16, 2021. 
 
You asked the Plan to pay for codes 43644 and 43281. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. 
 The service at issue in this appeal was billed with code 43644. This code is listed with a status indicator of "C" 
on Addendum B of the 2021 OPPS/ASC final rule. This means the service has been designated as "inpatient 
only", and therefore must be billed as part of an inpatient admission. 
 
The rules also say that Medicare does not pay for all other services on the same day as the inpatient only 
procedure. Code 43281 was performed on the same day as code 43644, which is an inpatient only code. 
 
Therefore, we decided that the Plan does not have to pay for the surgical services (43644 and 43281) provided 
from September 15, 2021, to September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on December 6, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on 
December 6, 2021, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve Gamunex-C. 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 Gamunex-C. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drug(s). There is no documentation provided indicating that the plans 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 Gamunex-C have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C.
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 you need acute rehabilitation to get back to doing 
things by yourself. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 
not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in 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 pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
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 you are at risk for de-conditioning without receiving 
proper care at an inpatient rehabilitation facility. The Plan denied your request. The Plan says authorization 
denied because the IRF care is not medically necessary, and your needs can be met at a lower level of care such 
as a skilled nursing facility (SNF). 
 
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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on January 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on April 
13, 2021. 
 You asked the Plan to pay for codes 81206 and 81292. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206 and 81292) provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on April 28, 2021. 
 
You asked the Plan to pay for code 0013M. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0013M) provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 16, 
2021. 
 
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 this was not coded correctly. 
 
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 62905 is "Removal foreign body from external auditory 
canal; with general anesthesia." 
 
We looked at the file and Medicare rules. Procedure code 69205 exceeds the allowable units of service for this 
date. 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 pay for surgical services provided to the enrollee on 
November 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Olmesartan-Hydrochlorothiazide tablet 40-25mg for the 
enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says drug coverage is only limited to those covered under the medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Olmesartan-
Hydrochlorothiazide tablet 40-25mg for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG)-positron emission 
tomography (PET) scan of the brain. 
 
You asked the Plan to pre-approve the scan. You say that the requested service is required to verify the cerebral 
metabolism. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case the 
records, provided indicate that you have a problem with balance and their gait and a tremor. While the provider 
has ordered a PET/CT of the brain to evaluate for cerebral hypometabolism, such testing is not readily 
consistent with standards of care. This type of testing is not generally performed in the evaluation of balance or 
movement problems. This test has not been shown to lead to any improvements in patient management or care. 
In as much it cannot be determined to be the most appropriate service or supply that can be provided to you. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan of the brain.