Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not have a history of failure, contraindication, or 
intolerance to oral bisphosphonate. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of oral 
bisphosphonate before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drug. There is no documentation provided indicating that the Plans required drug would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in tub (99199). 
 
You asked the Plan to pre-approve a walk-in tub. You say that you need this item. The Plan denied your 
request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in tub (99199).
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility. 
 
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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was evaluated by telehealth on April 19, 2023 for low back pain and physical therapy was prescribed. There is 
ongoing back pain and difficulty with activities of daily living. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. There is not a reasonable expectation that this 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON IRF care. You say that the enrollee would like to receive services at 
the requested facility. The Plan denied your request. The Plan says this is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services to be provided by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 10, 2022, 
through October 13, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the services in dispute were 
medically necessary. The Plan denied your request. The Plan says the services were not authorized. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found there was no 
documentation provided indicating medical necessity for post-stabilization care services at the non-plan 
facility. The enrollee was stable and appropriate for ambulance transport with monitoring to a plan facility for 
observation/admission level of care services after the emergency room evaluation. The review has determined 
that the treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee 
was not stable for transfer on any dates of service. 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided on October 10, 2022, through October 13, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FoundationOne Liquid Biopsy.  
You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that NGS is covered for the indications established in the 
applicable NCD. 
 
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 testing. Our reviewer says that the 
requested FoundationOne Liquid Biopsy is not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has malignant neoplasm of ampulla of Vater, stage IIA. There was no provided 
report of recurrence or advanced staging of this enrollee's cancer diagnosis to justify genetic testing, and so the 
NCD criteria are not met. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve FoundationOne Liquid Biopsy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee requires this imaging. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the service is not 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99457 billed for date of service June 22, 2022. 
 
You asked the Plan to pay for code 99457. You say that you provided these Medicare-covered services, so this 
claim should be paid. The Plan denied your request. The Plan says that this procedure has been billed and 
allowed the maximum number of times allowed by the Plan's payment policy. 
 
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. Specifically, in the very limited case file the Plan supplied, the Plan's only 
rationale for denial is that this code was billed more times than allowed per the Plan's policy.  However, the 
Plan has failed to provide a copy of this policy or a citation to any rule that would support this assertion.  
Further, the Plan has failed to provide any evidence that this code has ever been billed or paid more than on the 
one claim that is currently in dispute.  The burden is on the Plan to show why its denial is correct.  By failing to 
provide this information, we find that the Plan has not met this burden. Therefore, we decided that the Plan has 
to pay for code 99457 billed for date of service June 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine exam (99396) provided on November 22, 2022. 
 
You asked the Plan to pay for the routine exam. You say that the service should be covered. The Plan denied 
your request. The Plan says this benefit has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the routine exam (99396) provided on November 
22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable harness 
(E2313), and electronic connector (E2311). 
 
You asked the Plan to pre-approve upgraded electronics. You say that the enrollee is a paraplegic, has multiple 
unhealing pressure wounds and is not able to pressure relieve independently. You also say that the expandable 
controller system, harness and connector are medically necessary for the enrollee. The Plan denied your 
request. The Plan says an expandable controller and expandable harness cannot be covered as it is not 
medically necessary to control the three requested power options through the joystick. 
 
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 upgraded electronics. Our reviewer says 
that the requested upgraded electronics are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates that the enrollee has adequate strength to 
operate individual switches for multiple power drives. Therefore, the reviewer found that the requested 
upgraded electronics are 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377), expandable harness (E2313), and electronic 
connector (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing for the wrongful 
denial for intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. 
The Plan denied your request. The Plan says the records do not show that the enrollee meets the criteria for the 
surgical procedure. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for vertebrogenic low back pain and presented with 
low back pain that is worsening overall. The pain is worsened by standing, stairs, twisting, bending, and lifting. The pain is improved by medication. However, the magnetic resonance imaging (MRI) from December 6, 
2022, did not corroborate Modic type changes at the requested procedure level. Additionally, there were/are 
multiple plausible pathologic sources of significant pain generation. The back pain, the noted pain-aggravating 
factors (standing, stairs, twisting, bending, and lifting), pain-relieving factors (medications), along with the 
diminished spinal motion (in all directions), and intact neurologic exam were/are all non-specific to any 
pathologic entities. Overall, the documentation is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. The documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L4, L5, 
and S1 vertebral bodies, 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service September 20, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were necessary and are supported in the medical records. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service September 20, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an ophthalmological exam provided on December 29, 2022. 
 
You asked the Plan to pay for the ophthalmological exam. You say that the optometrist took special care and 
time to examine your eyes more closely because of the macular degeneration. The Plan denied your request. 
The Plan says that the exam is not a covered benefit. 
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial for this eye exam that was rendered due to a medical diagnosis. Therefore, we decided 
that the Plan has to pay for an ophthalmological exam provided on December 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0457) and hip brace (L1686) provided on 
October 3, 2022. 
 
You asked the Plan to pay for the back and hip braces. You say that the items were medically necessary. The 
Plan denied your request. The Plan says the submitted documentation in support of the medical necessity for 
these items was not provided by your treating provider following a face-to-face encounter. Rather the 
documentation indicates that a healthcare professional with a financial interest in the claim outcome provided 
the order and clinical summary without use of objective beneficiary specific information for diagnosing, 
treating, or managing your clinical condition. 
 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 relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation submitted does not include the date of visit or if the member was seen face to 
face or through a Medicare approved telehealth visit. 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 the back brace (L0457) and hip brace (L1686) provided on October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen concentrator. You say that the enrollee uses a walker and is very 
difficult for them to move around with oxygen tanks The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for the requested portable oxygen concentrator. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 oxygen concentrator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has chronic obstructive pulmonary disease (COPD) and is on 
supplemental oxygen. The enrollee uses a walker and is having difficulty managing the portable tanks while 
using the walker. There is no documentation that an oxygen saturation (SpO2) of greater than 91% can be 
maintained during activity using an oxygen conserving device at a flow rate of 1 to 4 L/min. This is required by 
Medicare for coverage of a portable oxygen concentrator. A portable oxygen concentrator is not medically 
necessary because the Medicare criteria are not met. 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the portable oxygen concentrator (E1392).