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

 
We decided that the Plan does not have to pay for the genetic testing services provided on August 10, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment for medical necessity. The Plan denied your request. The Plan says this claim has 
not been billed as required by Medicare coding regulations. 
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP device tubing provided on January 4, 2022 to January 
9, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for CPAP device tubing. You say that you can get the documentation that is 
necessary. The Plan denied your request. The Plan says the claim was denied because the requested 
documentation was not received within the allotted time from. 
 
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 CPAP device tubing provided on January 4, 2022 
to January 9, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Panzyga 10%. 
 
You asked the Plan to pre-approve Panzyga 10%. 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 Panzyga 10%. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has a diagnosis of small fiber sensory neuropathy associated with Sjogren's syndrome. The Food and 
Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 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 Panzyga 10% have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Panzyga 10%.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid-circulating cold pad with pump. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request will be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
Medicare does not consider this request to be reasonable or necessary. 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 a fluid-circulating cold pad with pump.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and had routine chronic foley catheter care. The enrollee was at a maximal assist level for 
functional mobility. He does not require skilled nursing or therapy services on a daily basis. The enrollee does 
not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Xarelto.  
 
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our physician 
reviewer found that the clinical documentation states that the enrollee is limited in community level 
ambulation, however there is no evaluation with a walker. The physical therapy evaluation states that the 
enrollee does not require power mobility device. It also states that he owns a power mobility device which is 
working appropriately and only requires a new battery. Based on the functional documentation a new power 
mobility device is not medically necessary or appropriate. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health physical therapy and 
occupational therapy services. 
 
You asked the Plan to pre-approve continued home health physical therapy and occupational therapy services. 
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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued home health physical therapy 
and occupational therapy services. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee does not have documented skilled therapy needs. The enrollee is 
functioning at a level commiserate with a lower level of care. As such, ongoing home health therapy services 
are not medically necessary or 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 continued home health physical therapy and occupational therapy services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health physical 
therapy and occupational therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural steroid injection. 
 
You asked the Plan to pre-approve transforaminal epidural steroid injection. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat transforaminal epidural steroid injections are 
only covered once every three months. 
 
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 transforaminal epidural steroid 
injection. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain and lumbar 
radiculopathy. The enrollee had a transforaminal epidural steroid injection on March 14, 2022 and had 
significant relief. However, a request to repeat the epidural steroid injection was made on May 5, 2022 which is 
before the three month time period described in the LCD criteria. Therefore, the enrollee did not meet criteria 
for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transforaminal epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transforaminal epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pelvic fixation (attachment of caudal end of 
instrumentation to pelvic bony structures) other than sacrum (CPT code 22848). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the enrollee's records do not show that their symptoms correlate with the imaging 
provided, nor that the enrollee has had a trial of conservative management. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, the imaging studies provided for review 
do not corroborate a pseudoarthrosis as noted on the exam. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, requested pelvic fixation (attachment of caudal end of instrumentation to pelvic bony 
structure) other than sacrum CPT 22848, 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) 
other than sacrum (CPT code 22848).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 34 home health aide visits. 
 
You asked the Plan to pre-approve 34 home health aide visits. 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 HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 34 home health aide visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not 
have documented skilled nursing needs or skilled therapy needs. Home health aide (HHA) services are not 
shown to be medically necessary to assist in the treatment of acute illness or injury. The enrollees care needs 
are custodial and long-term. As such, the requested HHA services are not medically necessary or 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 34 home health aide visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 34 home health aide visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle libre 2 sensor kit. 
 
You asked the Plan to pre-approve the sensor. You say that the item is necessary. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
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 patient is not using insulin three or more times per day or is 
using an insulin pump. Pharmacy claim history show the patient is only one long-acting insulin. Based on this 
information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Freestyle libre 2 sensor kit.
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 does not meet 
criteria. 
 
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 enrollees medical conditions are stable on outpatient medications with no issues 
that require a physicians evaluation three or more times per week. Provided records do not explain why the 
intensive inpatient rehabilitation therapy program is necessary. The enrollee does not require intense 
rehabilitation and there is concern that she will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility (due to some reported refusal to 
participate with therapy in the hospital). Records do not clarify that treatment at the skilled nursing facility 
level is not appropriate in this case. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 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 services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have severe chronic obstructive pulmonary disease (COPD), moderate to severe aortic stenosis 
with heart failure with reduced ejection fraction (HFrEF), and transudative pleural effusions. The partial 
pressure of carbon dioxide (PaCO2) was increased during a recent hospitalization for congestive heart failure 
(CHF) with pleural effusions. You may benefit from bilevel positive airway pressure (bipap) during sleep in the average volume-assured pressure support (AVAPS) mode, especially considering you have obstructive sleep 
apnea (OSA). But Medicare does not cover a home ventilator when used as bipap. 
 
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.
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 requires LTACH because he 
has a complexity of care needs, recent hospitalizations, and has failed at a lower level of care. The Plan denied 
your request. The Plan says authorization denied because the LTACH 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 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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (CPT code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the services are medically necessary. The Plan 
denied your request. The Plan says this medication can only be approved when there is enough evidence to 
show that it is safe and helpful for the enrollee's specific condition. The Plan states this medication can only be 
approved for the enrollee's condition when other treatment has not worked. The Plan states because the enrollee 
has had no other treatment, this medication cannot be approved at this time. 
 
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 medication. Our physician reviewer 
found per FDA label and compendia need pdl1+ to treat for first line metastatic disease. TMB H is reserved for 
patients with no other reasonable alternatives. This enrollee has not had first line chemo with a platinum 
doublet in the alternative if egfr and alk wildtype could treat with carbo/alimta/keytruda. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab (CPT code J9271).