Persius/hicric huggingface dataset:
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 clinical documentation provided supports the 
need for IRF care. You say that the enrollee requires inpatient acute rehabilitation in effort to facilitate 
increased independence and return home and to his community with improved quality of life. The Plan denied 
your request. The Plan says the enrollee's care does not need to be managed by a rehabilitation doctor. The Plan 
says that special team meetings are not needed to provide the care needed. The Plan says that formal therapy 
team meetings are not needed to provide the care needed. The Plan says that the enrollee's treatment plan goals 
could be achieved in another setting. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although the 
enrollee certainly requires daily skilled nursing services for wound care, his condition does not appear to 
require a physicians evaluation three or more times per week. The enrollee may benefit from further physical 
therapy and occupational therapy services, but the medical records provided do not clarify why the enrollee 
requires an intensive inpatient rehabilitation therapy program. The provided records do not explain why the 
intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such as 
in a skilled nursing facility is not appropriate for the enrollee. The enrollee was recently discharged from home 
health therapy services as goals had been met and he had reached maximum. 
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 your medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation. You do require treatment by multiple 
therapies, including either physical therapy or occupational therapy given your decline in function. However, 
you do not require an intensive rehabilitation therapy program at least three hours a day and five days a week, 
or 15 hours over seven consecutive days, and it is uncertain if you would benefit and tolerate this level of 
intensity with regards to 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 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 coded 81479 provided on November 
21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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 CPT code 81479 is not supported in the medical record. Specifically, when a laboratory assays 
two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. 
A panel constitutes a single procedural code, so one code should be billed for the panel. Review of the file 
shows that this code was submitted on its own claim form; however, other codes were submitted on a different 
claim form, but the testing was performed on the same specimen. This means that one code was not submitted 
for the entire panel provided. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81479 provided on November 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide-Formoterol fumarate dihydrate Aerosol. 
 
You asked the Plan to pre-approve Budesonide-Formoterol fumarate dihydrate Aerosol. You say that this is 
medically necessary. The Plan denied your request. The Plan says coverage of this medication is the 
responsibility of the enrollee's prescription drug plan. 
 
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 Budesonide-Formoterol 
fumarate dihydrate Aerosol.  
 Benefits for Budesonide-Formoterol fumarate dihydrate Aerosol 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you are requesting reconsideration as you 
do not have any other way to get to this appointment. The Plan denied your request. The Plan says you are 
requesting an additional 8 miles for a total of 58 miles and your benefit only allows 50 miles. The Plan also 
says you have exceeded your benefit limit. 
 
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 up to 12 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Herceptin for the enrollee. 
 
You asked the Plan to pre-approve Herceptin. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the Medicare-approved drug compendia and cancer journals do not support the use 
of the requested drug regimen for treatment of the member's condition. 
 
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 Herceptin. Our reviewer says that 
Herceptin is not medically reasonable and necessary. Herceptin is not FDA-approved for the enrollees 
diagnosis. The use of Herceptin is not supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of Herceptin. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Herceptin have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Herceptin for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kimyrsa IV infusion for the enrollee. 
 
You asked the Plan to pre-approve the infusion. You say that this is medically necessary. The Plan denied your 
request. The Plan says if treatment of infection/colonization is felt to be necessary, the enrollee can be treated 
with oral antibiotics such as amoxicillin. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the infusion. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that Kimyrsa is not 
indicated for venous stasis ulcers or diabetic foot ulcers. The review has determined that the documentation did 
not support that the Kimyrsa is medically reasonable and necessary for the patient. The documentation did not 
support that the Kimyrsa is safe and effective for the patient. 
 
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 infusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Kimyrsa IV infusion for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system to help keep the enrollee's lung open 
and free of mucous. 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says there is no data to support the effectiveness of the device. 
 
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 service. Our physician reviewer 
found the Volara System is not medically necessary. The enrollee does not have cystic fibrosis, bronchiectasis, 
or neuromuscular disease. The Volara System combines airway pulse oscillation, nebulization, and positive 
end-expiratory pressure. The enrollee already has a nebulizer, so this would be duplicated. There is no clearly 
demonstrated benefit of either airway oscillation or "lung expansion" in the outpatient treatment of chronic 
obstructive pulmonary disease (COPD) or pulmonary fibrosis. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Volara system to help keep the enrollee's lung open and free of mucous.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on May 12, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sanexas neo-GEN Series treatment. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has a history of peripheral 
neuropathy. You state the enrollee's symptoms of proprioceptive loss and painful neuropathy have increased 
despite oral medication therapy. You state that you express concerns of the enrollee injuring themself due to 
their current symptoms/medical history and feel the enrollee would benefit from treatment. The Plan denied 
your request. The Plan says the requested Sanexas neo-GEN Series treatment is considered investigational, as 
best evidence does not indicate effectiveness of proposed treatment. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. The device itself has not been clearly 
documented to be fully Food and Drug Administration (FDA) approved. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested Sanexas neo-Gen series treatment, in this case, is not medically reasonable or 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sanexas neo-GEN Series treatment.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two (2) injections. We decided that the Plan does not have to pre-
approve one (1) injection.  
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan says that the 
medical records show that the enrollee does not have pain for at least three months, and the enrollee also does 
not have a plan for their doctor to give the enrollee shots for only two joint levels at the same time. 
 
We decided that the Plan has to pre-approve two (2) injections.  
 
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 physician reviewer 
found the LCD limits the number of diagnostic blocks to 2 levels. The first two levels are 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve two (2) injections.  
 
We also decided that the Plan does not have to pre-approve one (1) injection. 
 
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 one (1) injection. Our physician 
reviewer found the third level request is deemed not medically reasonable or 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 one (1) injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve one (1) injection. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
device. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM device.. You say that the enrollee is disabled and 
unable to leave her home. She needs the requested item to monitor her diabetes. The enrollee cannot use other 
monitors due to limitations in her motor skills. The Plan denied your request. The Plan says the enrollee does 
not meet prior authorization criteria. 
 
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 and 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 a Freestyle Libre 2 CGM device. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
September 4, 2021, through October 4, 2021. 
 You asked the Plan to pay for the SNF care. You say that this care was medically reasonable and necessary. 
The Plan denied your request. The Plan says the rules for SNF care were not met. 
 
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 pay for the SNF care. Our reviewer says that the 
requested SNF care is medically reasonable and necessary. Our physician reviewer found the enrollee is a 77-
year-old female long-term care resident with hospitalization for urinary tract infection and metabolic 
encephalopathy. In this case, there were no identifiable skilled nursing service needs and no identifiable skilled 
therapy service needs. In conclusion, this enrollee did not meet severity of illness or intensity of service criteria 
on an inpatient basis in a skilled nursing facility 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from September 4, 2021, through October 4, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (CPT code 0013M) provided on 
January 20, 2022. 
 
You asked the Plan to pay for the CxBladder testing. You say that CxBladder Monitor provides the information 
necessary to make informed decisions, while also providing the opportunity for improved patient compliance 
and potential elimination of additional invasive urological work-up procedures and diagnostic tests. The Plan 
denied your request. The Plan says your request does not meet Medicare rules because a review of the medical 
literature and clinical practice guidelines does not support the clinical utility of CxBladder. 
 
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 CxBladder testing. Our physician 
reviewer found 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 the CxBladder testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the CxBladder testing (CPT code 0013M) provided on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CPAP device and heated humidifier (CPT code(s): 
E0601RR and E0562RR). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the documentation provided for review indicates you are not compliant with the use of 
the device. 
 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 DME. Our physician reviewer 
found you have been advised to increase usage, but there is no report of an additional download since the visit 
of April 21, 2022.  If the provider can show from a more recent download that you haves been able to meet 
minimum usage, then continued CPAP coverage should be approved. If more recent data cannot be provided, 
or usage is less than 70%, the denial is upheld. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CPAP device and heated humidifier (CPT code(s): E0601RR and E0562RR).