Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on October 31, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
were reported with the incorrect DRG. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code J96.91, defined by 
respiratory failure, unspecified with hypoxia; and secondary diagnosis code T79.1XXA, defined as fat 
embolism (traumatic), initial encounter. 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 
services provided. Our physician reviewer found that the enrollee was admitted to the hospital for a cardiac 
arrest secondary to a pulmonary embolism, suspected to be a complication from femur fracture surgery. After 
review of the record, the cardiac arrest secondary to the pulmonary embolism from the recent surgery was the 
condition that circumstanced the admission. As noted, the embolism was secondary to recent orthopedic 
surgery, therefore the complication code would be sequenced first. The review has determined that the 
diagnoses, and therefore DRG, at issue were not supported in the medical records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on October 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Radicava Ors starter kit. 
 
You asked the Plan to pre-approve a Radicava Ors starter kit. You say that you would like Radicava Ors to be 
approved to be on the enrollee's formulary list of medications. The Plan denied your request. The Plan says 
Radicava Ors is a self-administered drug and does not fall under Part B coverage. 
 
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 a Radicava Ors starter kit.  
 
Benefits for a Radicava Ors starter kit 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: 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 this member is still greatly in need of inpatient 
rehabilitation level of care. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information they have about the enrollee's condition; she does not meet the requirements. 
 
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
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 reasonable and necessary. 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 (J1439).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on December 6, 2021. 
 
You asked the Plan to pay for a new patient office visit. You say that you believe this visit was denied in error. 
The Plan denied your request. The Plan says the Plan has limited chiropractic benefits and this service is 
excluded. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a new patient office visit provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation. 
 
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that sacroiliac joint 
radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says sacroiliac joint 
radiofrequency ablation does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation used for sacro-iliac joint pain 
is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed 
radiofrequency. 
 
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 sacroiliac joint radiofrequency ablation. 
Our reviewer says that sacroiliac joint radiofrequency ablation is not medically necessary. Our physician 
reviewer found this is considered an experimental/investigational procedure because of the wide variation in 
efficacy reported in the literature. Therefore, the 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 sacroiliac joint radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation clearly shows medical complexity of the case as the enrollee would benefit from 
close medical monitoring on an inpatient basis focused on rehabilitation. The enrollee has documented acute 
functional impairments in 3 disciplines of therapy (speech therapy, occupational therapy and physical therapy). 
The evaluating therapists and provider states that the enrollee would be expected to tolerate intense 
rehabilitation and a 1-2 week period of time given. Hip fracture is a IRF compliant diagnosis. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (urothelial), mRNA, gene expression profiling 
by real-time quantitative PCR of five (0012M) provided August 13, 2021. 
 
You asked the Plan to pay for CxBladder Detect. You say that you believe that the evidence supporting the use 
of CxBladder Detect as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says this test is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. CxBladder Detect has not been evaluated for Medicare coverage by 
the MolDx Program administered by Palmetto GBA. Only CxBladder Monitor has been evaluated and it is 
noncovered. This test is 
then considered non-covered by Medicare using the Palmetto Molecular Diagnostics Program. Based on this 
information, we decided that Medicare rules for coverage of CxBladder Detect have not been met. Therefore, 
we decided that the Plan does not have to pay for the oncology (urothelial), mRNA, gene expression profiling 
by real-time quantitative PCR of five (0012M) provided August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural steroid injection (TFESI). 
 
You asked the Plan to pre-approve TFESI. You say that TFESI is not medically necessary. The Plan denied 
your request. The Plan says the requested transforaminal epidural steroid injection does not meet the Medicare 
coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 TFESI. Our reviewer says that TFESI is 
not medically necessary. Our physician reviewer found the Medicare LCD criteria is at least 50% pain relief for 
3 months, which was not achieved in this case. Therefore, the 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 TFESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transforaminal epidural steroid injection (TFESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have information on patient insurance 
requirements, limitations, or conditions. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of a semi-electric 
hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 this item. Our reviewer says that you do 
not meet criteria for coverage of a semi-electric bed. Our physician reviewer found that in this case, the 
documentation doesnt support that you have a condition that requires frequent positioning of the bed and 
mattress to alleviate pain, promote good body alignment, prevent contractures or avoid respiratory infections in 
a way that an ordinary bed is not able to. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory/testing services on September 
16, 2021. 
 
You asked the Plan to waive the copayment for laboratory/testing services. You say that you didn't know there 
was going to be a copay. The Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $20 copayment for laboratory/testing services.  
 
The enrollee has been asked to pay a $20 copayment for laboratory/testing services. laboratory/testing services 
falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for laboratory/testing services on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing provided on September 29, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the test informs clinicians about which 
medications may require dose adjustments. The Plan denied your request. The Plan says there is no clinical 
indication for MTHFR genotyping in any population. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 81291 is MTHFR (5,10-methylenetetrahydrofolate 
reductase) (e.g., hereditary hypercoagulability) gene analysis, common variants. We find that the MTHFR gene 
is only covered for those who are pregnant.  
 
We also find that the GeneSight testing is not supported in the records. The records provided do not show that 
the testing was ordered based on the treating clinician has already considered non-genetic factors to make a 
preliminary drug selection. The testing is not considered reasonable and necessary merely on the basis of a 
patient having a particular diagnosis. Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
pharmacogenomics testing provided on September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Feraheme. Our reviewer says that the 
requirements for coverage of Feraheme have not been met. Our physician reviewer found the Plan requires a 
trial of Ferrlecit, Sodium ferric gluconate, Infed, or Venofer before they will approve the requested drug. The 
enrollee has not tried and failed any of these drugs. The documentation does not support that Ferrlecit, Sodium 
ferric gluconate, Infed, or Venofer would likely be less effective or 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the durable medical equipment (DME) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the DME. You say that there are no in-network providers that can provide 
the DME that the enrollee needs. The Plan denied your request. The Plan says the requesting provide is an 
OON provider and a list of in-network providers was given to the enrollee that provide the DME that they 
need. 
 
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 
the durable medical equipment (DME) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve additional OT visits. You say that the enrollee needs continued OT services. 
The Plan denied your request. The Plan says the requested services are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 additional OT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. Our reviewer also found that the additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore are 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 additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional occupational therapy (OT) visits.