Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a purchase of durable medical equipment (DME). 
 
You asked the Plan to pre-approve a purchase of DME. You say that you disagree with the denial due to the 
enrollee's medical condition. The Plan denied your request. The Plan says there is no documentation that the 
enrollee meets criteria for expanded benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a purchase of DME have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve a purchase of durable medical equipment (DME).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima, Udenyca, and Dexamethasone. 
 You asked the Plan to pre-approve the drugs. You say that this is medically necessary for the patient's treatment 
of stage 3 GCB-Diffuse large B-cell lymphoma. The Plan denied your request. The Plan says the step therapy 
requirements are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drugs. Our reviewer says that the 
requested drug regimen is not medically reasonable or necessary. Our physician reviewer found that in terms of 
the step therapy issue for Truxima, the provided records do not indicate that the enrollee has tried and failed the 
plan's preferred step one alternative. 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 - Ruxience or Riabni. The elements 
of the coverage criteria are not satisfied.  
 
In terms of the other drugs, the record indicates that the enrollee has a diagnosis of stage 3 GCB-Diffuse large 
B-cell lymphoma. The record indicates that the enrollee is prescribed a chemotherapeutic regimen that has a 
low (less than 10%) incidence of clinically significant febrile neutropenia. The Food and Drug Administration 
has not stated that Udenyca is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of Udenyca in the enrollee's clinical situation. No 
literature from Medicare approved cancer journals were submitted for review. The elements of the coverage 
criteria are not satisfied. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima, Udenyca, and Dexamethasone.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you would not ask for this machine if you were 
confident enough to get another positive airway pressure (PAP) machine. The Plan denied your request. The 
Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be paid.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.
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 enrollee needs to return to prior level of function 
meeting full criteria and needs physical and occupational therapy. The Plan denied your request. The Plan says 
the enrollee does not require an intensive and coordinated interdisciplinary approach to your rehabilitation and 
your rehabilitation is not complex, medically necessary care may be provided safely in a different 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 there is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found Medicare NCD 
states:  "Repeat ESI when the first injection directly and significantly provided improvement of the condition 
being treated may be considered medically reasonable and necessary when the medical record documents at 
least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline 
using SAME scale* for at least three months." This criteria has not been met and therefore, the request is 
deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the step therapy requirements 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 the drug. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the enrollee is 
noted to have iron deficiency.  A request has been made for Injectafer to treat the iron deficiency. The health 
plan requires that other forms of IV iron be used/tried first. There is no evidence that the enrollee is allergic to 
or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and not 
responded to these other forms of medication. There is no documentation as to why these other forms of 
medication would not be expected to be safe and effective for the enrollee. Therefore, the requested Injectafer 
is not shown to be currently medically necessary and reasonable.  
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says under Medicare rules, this request is 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 pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation in the medical record does not support that the enrollee's wound has not 
responded to standard wound treatment for at least a 30-day period during organized comprehensive 
conservative therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Epifix.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from LTACH 
care for further wound care needs and increased nutrition along with physical and occupational therapy. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) care to be provided 
by an out-of-network (OON) provider at the in-network benefit level. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this decision. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan and the enrollee could be treated 
within the Plan network. The Plan also says the enrollee may utilize this provider at the out-of-network benefit 
level. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers, but the share of costs for 
covered services may be higher. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network benefit level. The enrollee may choose to utilize 
this provider at the out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-
approve inpatient rehabilitation facility (IRF) care to be provided by an out-of-network (OON) provider at the 
in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on August 1, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the records do not 
show that the items were delivered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the records do not show that the supplies were delivered. 
However, the packing slip dated August 1, 2022, shows the same tracking number as the delivery ticket on 
page 31 of the case file. As the documentation shows that the items in question were delivered, the Plan's denial 
cannot be substantiated. Therefore, we decided that the Plan has to pay for the electrical stimulator supplies 
provided on August 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided February 22, 2021, to 
March 23, 2021. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 home health services are not supported in the medical record. Specifically, the documentation 
did not contain the visit notes for the billed visits from February 22, 2021, to March 23, 2021. Without this 
required documentation, the services billed are not supported. 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 the home health services provided February 22, 2021, to March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional two months rental of a wound vacuum 
device. 
 
You asked the Plan to pre-approve the continued rental. You say that this is medically necessary to get the 
wound stabilized while waiting for the skin graft surgery. The Plan denied your request. The Plan says a wound 
vacuum device may be approved for a maximum of four months. 
 
Medicare rules say that only four months of an NPWT pump is covered being the pump stops being covered. 
 
Two additional months of rental would not be covered, as four months have elapsed. Based on this information, 
we decided that Medicare rules for coverage of the continued rental have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an additional two months rental of a wound vacuum device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4253 billed for date of service June 10, 
2022. 
 
You asked the Plan to pay for procedure code A4253. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4253 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4253 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4253 is excluded/not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code A4253 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4253 billed for date of service June 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that medical records were submitted for review. The 
Plan denied your request. The Plan says that the admission to a SNF is not medically necessary. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repairs and modifications to a foot orthosis provided from 
February 9, 2022, to March 21, 2022. 
 
You asked the Plan to pay for foot orthosis repairs. You say that you are requesting payment. The Plan denied 
your request. The Plan says the Plan cannot determine how the enrollee came to be serviced by this provider. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. Specifically, although repairs do not require a new 
certificate of medical necessity or order, the original physician order for this foot orthosis was also not submitted to support coverage. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for repairs and 
modifications to a foot orthosis provided from February 9, 2022, to March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on June 7, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a pneumatic compression device and related accessories were provided to the enrollee after 
knee surgery. The records do not show persistent chronic and severe lymphedema or a failure of a four-week 
trial of conservative therapy. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device and related supplies provided on June 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on October 18, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 7, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on March 7, 2022.