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

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Retacrit or Procrit. 
 
 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 Aranesp. Our physician reviewer found 
that in this case, the record indicates that the enrollee has anemia of chronic kidney disease. The requested 
medication is a new start. The Plan requires a trial of Retacrit or Procrit before they will approve the requested 
drug. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a taller or adjustable height walker. 
 
You asked the Plan to pre-approve the requested walker. You say that the walker you have hurts your back by 
the end of the day. The Plan denied your request. The Plan says there were no medical records provided to 
show the current walker does not meet your needs in the home.  
 
The Plan must follow Medicare rules. The rules say if DME serves the same purpose as equipment already 
available to an enrollee, it is not considered reasonable and necessary. The file shows that you have standard 
walker. This walker serves the same purpose as the requested walker. Therefore, we decided that the Plan does 
not have to pre-approve a taller or adjustable height walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you have bad scoliosis, cannot walk, and are 
confined to her home. The Plan denied your request. The Plan says that there is no documentation of a mobility 
deficit which limits your ability to complete activities of daily living in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have a 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.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your 
condition can be improved by a walker, cane or manual wheelchair or that you can safely operate the PMD 
being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a floor level hospital bed. 
 
You asked the Plan to pre-approve a floor level hospital bed. You say that a floor level hospital bed is 
medically necessary. The Plan denied your request. The Plan says a floor level hospital bed is not covered by 
Medicare. The Plan notes because the enrollee is dual eligible, this request should be submitted under 
their Medicaid benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare does not cover a floor level hospital bed under Medicare. Therefore, we 
decided that the Plan does not have to pre-approve a floor level hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental anesthesia. 
 
You asked the Plan to pre-approve the dental anesthesia. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested anesthesia is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says that 
the requested anesthesia is not medically necessary.  Our physician reviewer found the documentation provided does not meet the criteria for coverage for the use of 
general anesthesia rather than local anesthesia for the extraction of teeth # 2, 3 and 14. There was no indication 
of a medical condition which would make general anesthesia medically necessary over local anesthesia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental anesthesia have not been met.  Therefore, we decided that the Plan does 
not have to pre-approve dental anesthesia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from April 
5, 2022, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found the records provided for the admission does not meet the criteria for April 5, 2022, 
forward as you were not shown to be a danger to yourself or others, delusions, auditory or visual hallucinations 
noted. You were cooperative/compliant with treatment while not showing any threats the safety. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from April 5, 2022, forward.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria 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 Ilumya. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Humira, Enbrel or Skyrizi before they will approve the requested drug. In this case, the the patient has 
not tried and failed the required drug(s). In this case, the patient has not tried and failed the required drug(s). 
There is no documentation provided indicating that the plans required drug(s) 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing for 22 or more drug classes 
(G0483) provided September 7, 2021. 
 
You asked the Plan to pay for the drug testing. You say that do to the expansive clinical value of the testing you 
do that benefits the enrollee, you ask for reconsideration of the denial and request payment in full for the testing. The Plan denied your request. The Plan says under Medicare rules the request for definitive urine drug 
testing of this number of drug classes is considered not medically reasonable and necessary 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
definitive urine drug testing for 22 or more drug classes (G0483) provided September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging services (78452) to be 
provided by an out-of-network (OON) provider. 
 You asked the Plan to pre-approve myocardial perfusion imaging services. You say that this care is medically 
necessary to be provided by an OON provider the enrollee has seen in the past. The Plan denied your request. 
The Plan says there are in-network providers available to provide these services. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 myocardial perfusion imaging services. 
Our reviewer says that it is not medically necessary for these services to be performed by an OON provider. 
Our physician reviewer found that the patient is a 76-year-old female who is seeing an out of network provider 
for shortness of breath. Myocardial perfusion imaging was requested as the patient was not able to walk on the 
treadmill for a standard stress test. Although this test appears to be appropriate, there is no emergency need as 
the patient was stable and there was no clear explanation provided as to why the patient could not effectively 
receive this test and follow-up with an in-network provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial perfusion imaging services (78452) to be 
provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Infed (iron dextran) 
and Venofer (iron sucrose). 
 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 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternatives. 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. Therefore, the reviewer found that the step therapy criteria have not been 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 20, 2021 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you are hoping the 
Plan will reconsider paying for the exam because it was an emergency. The Plan denied your request. The Plan 
says this service exceeds the frequency limitation in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on November 16, 2021 and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on November 20, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ROMtech portable connect adaptive rehab device. 
 
You asked the Plan to pre-approve the ROMtech portable connect adaptive rehab device. You say that this 
device is medically necessary. The Plan denied your request. The Plan says the requested equipment is not 
primarily medical in nature. 
 
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 the ROMtech portable connect adaptive rehab device.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Synvisc/Synvisc-One and Durolane/Gelsyn-3. 
 
 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 Orthovisc. Our physician reviewer 
found that you have knee osteoarthritis and related pain. The Plan requires a trial of Synvisc/Synvisc-One and 
Durolane/Gelsyn-3 before they will approve the requested drug. The provided records did not clearly show that 
you have tried and failed Synvisc, Synvisc-One, Durolane, or Gelsyn-3. The above preferred agents by the Plan 
will not likely be less effective or less safe for the patient as currently available comparative studies show 
essentially equal effectiveness and safety for all agent in this class. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
hypoxemia and atelectasis after recent kyphoplasty of vertebral fractures. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.  While you have a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) 
(87507) provided August 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please reconsider this claim for payment in 
full. This was not a duplicate. The claim had been sent corrected with diagnosis codes added. Please review and 
reprocess for payment in full. The Plan denied your request. The Plan says duplicate claim, original paid to 
same tax ID. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87507 is infectious agent detection by nucleic acid (dna 
or rna); gastrointestinal pathogen (eg, clostridium difficile, e. coli, salmonella, shigella, norovirus, giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 3-5 targets. 
 We find that CPT code 87507 is not supported in the medical record. Specifically to report a comprehensive 
genomic profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently 
satisfactorily described by any existing CPT code; to report a CGP, service providers should use 1-unit only of 
CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-
CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes, or other 
unlisted code. 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 infectious agent 
detection by nucleic acid (DNA or RNA) (87507) provided August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve battery backup for durable medical equipment. 
 
You asked the Plan to pre-approve battery backup. You say that battery backup is necessary if there is voltage 
decrease. The Plan denied your request. The Plan says precautionary equipment 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. Batter back up for any device is precautionary and is not covered by Medicare. Therefore, we 
decided that the Plan does not have to pre-approve battery backup for durable medical equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that compression stockings are 
medically necessary. The Plan denied your request. The Plan says the requested compression stockings are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  Although this item may be 
appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on September 30, 2021. 
 
You asked the Plan to pay for the dental guard. You say that your provider does not take Medicare or your 
insurance, so you paid $600 for this item up front. You do not understand why you are only being reimbursed 
$140. The Plan denied your request. The Plan says the Plan reimbursed you the allowed cost for this service in 
error but will not seek reimbursement of the $140 payment made to you. This service is not eligible for 
reimbursement because the provider in this case has opted-out of the Medicare program, and therefore this 
provider cannot accept Medicare payment and services rendered by this provider are ineligible for 
reimbursement. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9944) 
provided on September 30, 2021.