Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two Cosentyx pens. 
 
You asked the Plan to pre-approve the Cosentyx pens. You say that the enrollee is currently on samples of 
loading dose Cosentyx since January 18, 2023, with reduction of plaque and itching. The Plan denied your 
request. The Plan says Cosentyx is a self-administered drug, and is not covered for the enrollee's condition by 
Medicare Part B. 
 
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 two Cosentyx pens.  
 
  Benefits for the Cosentyx pens may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as the enrollee is in a 
lot of pain and has tried physical therapy. The Plan denied your request. The Plan says the notes do not show at 
least two diagnostic blocks. 
 
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 in this case, there have not been two diagnostic medial branch blocks with at least 80% relief. 
 
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 facet joint radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0364 and D0140) on June 2, 2022. 
 
You asked the Plan to pay for the dental services (D0364 and D0140). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the dental service (D0364) is 
not a covered benefit. The member received dental service (D0140) from an out-of-network provider, and they 
are responsible for any amount greater than the payment made by the plan to the provider. The member was 
correctly assessed a liability amount of $93.00 ($145.00 - $52.00). 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D0364 and D0140) on June 2, 2022.
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 would benefit from inpatient care and physical 
therapy. The Plan denied your request. The Plan says you do not meet Medicare criteria for admission to an 
IRF. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You have a past medical history of stroke and are living at home with ongoing weakness. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the medical records support a need for 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
you would 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you would like the medical records to be 
reviewed and the authorization to be reconsidered and approved. The Plan denied your request. The Plan says 
the requested device does not meet the requirements for approval. The request is not medically necessary 
because the records show that the requested device is to be used in a bi-level PAP mode (AVAPS-AE), which 
can be provided by another device. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found provided records document chronic 
respiratory failure consequent to chronic obstructive pulmonary disease, diastolic dysfunction, and sleep apnea.  
Provided records document that the home ventilator is being requested for use in average volume assured 
pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with 
AVAPS and a back-up rate.  As stated in the Local Coverage Determination (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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 SNF services are necessary for you to regain your 
strength. The Plan denied your request. The Plan says SNF services are 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing services provided on August 17, 
2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the claim did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The claim does not show that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing services 
provided on August 17, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lower extremity 
(73720). 
 
You asked the Plan to pre-approve an MRI of the lower extremity. The Plan denied your request. The Plan says 
that this request cannot be approved because the records do not show results of an x-ray that support further 
imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lower extremity. Our 
reviewer says that an MRI of the lower extremity is medically reasonable and necessary for the enrollee. Our 
physician reviewer found the enrollee is a diabetic with draining ulcer on the right plantar mid-foot. Probing 
exam goes to bone. Our reviewer found that an MRI is very reasonable and will be used to assess possible 
osteomyelitis. Our physician reviewer also found that the results of a plain x-ray would be meaningless as even 
if normal MRI would still be necessary to evaluate the soft tissues and bone. 
 
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 MRI of the lower extremity have been met. Therefore, we decided that the 
Plan has to pre-approve a magnetic resonance imaging (MRI) of the lower extremity (73720).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the appropriate level of 
care for this enrollee. You say the enrollee is medically stable to be transferred to the LTACH level of care at 
this time. The Plan denied your request. The Plan says the enrollee does not meet the criteria for an LTACH 
admission. 
 
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 the enrollee appears to be somewhat unstable and requires short-term additional acute 
care services that can safely be provided at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH 
would not be clinically advantageous and completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic counseling (96040), outpatient office visit 
(99205), and routine venipuncture (36415). 
 
You asked the Plan to pre-approve genetic counseling, outpatient office visit, and routine venipuncture. You 
say that your doctor recommends you have genetic testing done. You also say that you are about to have a 
double mastectomy. The Plan denied your request. The Plan says the requesting provider stated the reason for 
the genetic counseling was to determine whether genetic testing was needed in order to determine the 
appropriate treatment option of breast preservation versus total mastectomy. The Plan also says the requesting 
provider stated the rationale for the genetic counseling no longer exists, as you already underwent a total 
mastectomy. 
 
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 genetic counseling, outpatient office 
visit, and routine venipuncture. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you 
have recurrent breast cancer and have now undergone bilateral mastectomy. The record does not indicate how 
the requested test would alter your treatment plan. Our reviewer found that the record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. Our reviewer also found that the requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic counseling, outpatient office visit, and routine venipuncture have not 
been met. Therefore, we decided that the Plan does not have to pre-approve genetic counseling (96040), 
outpatient office visit (99205), and routine venipuncture (36415).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee has been provided medical clearance to undergo this 
elective procedure. The planned procedure is listed under code 23472 which is not listed on the CMS inpatient 
only list. The procedure is currently approved as an ambulatory procedure. There is no documentation provided 
to support the expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found the requested reverse total shoulder arthroplasty is documented to have 
been supported. However, detailed documentation is not evident regarding a significant past and/or current 
medical history that would place this enrollee at increased risk for peri-surgical complications requiring an 
inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the record does not show that at the time of 
inpatient admission, the admitting physician reasonable expected that the enrollees necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transit wheels (K0108). 
 
You asked the Plan to pre-approve the transit wheels. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is for use outside. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the transit wheels (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing of 15-21 classes (G0482) provided on 
September 14, 2022. 
 
You asked the Plan to pay for definitive drug testing of 15-21 classes. You say that you cannot afford the cost 
of this service. The Plan denied your request. The Plan says medical records are needed to review this claim. 
 
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 definitive drug testing of 15-21 classes 
have been met. The Plan sent multiple requests for medical records which were not received. Without thi 
information we cannot verify the medical necessity of the drug testing. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing of 15-21 classes (G0482) provided on September 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Injectafer. Our reviewer says that 
Injectafer is not medically reasonable and necessary for the enrollee. Our physician reviewer found 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. Our reviewer found that the elements of the coverage criteria are not 
satisfied. Our physician reviewer also found that 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 Injectafer 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 pay for the FreeStyle LIBRE 2 System (K0554) and sensor (K0553) 
provided on July 25, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor (CGM). You say that the items should be 
covered. The Plan denied your request. The Plan says there is insufficient documentation provided to support 
the need for these items. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of the continuous glucose monitor (CGM) have not been met. Therefore, we 
decided that the Plan does not have to pay for the FreeStyle LIBRE 2 System (K0554) and sensor (K0553) 
provided on July 25, 2022.