Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation or inpatient hospital care (99236) provided on 
September 6, 2021. 
 
You asked the Plan to pay for observation or inpatient hospital care (99236). You say that the patient was seen 
in an emergency situation and the medical documentation shows the consult was medically necessary. You say 
that the charges should be allowed. The Plan denied your request. The Plan says an initial observation care 
evaluation and management service (99220) was reported the day prior.  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 99236 is observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99236 is not supported in the medical record. Specifically, the billed code is not 
appropriate as the member was admitted the day prior. Based on this information, we decided that Medicare 
rules for coverage of observation or inpatient hospital care (99236) have not been met. Therefore, we decided 
that the Plan does not have to pay for observation or inpatient hospital care (99236) provided on September 6, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tresiba Flex injection, 200 units. 
 
You asked the Plan to pre-approve Tresiba Flex injection. You say that the requested drug is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 Tresiba Flex injection, 200 
units.  
 Benefits for Tresiba Flex injection 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Reader continuous glucose 
meter (CGM). 
 
You asked the Plan to pre-approve CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says the requested CGM is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day 
Reader continuous glucose meter (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the 
rehabilitation needs can be safely met in an alternate and lower intensity 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 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 pay for self-administered drugs received on October 16, 2021. 
 
You asked the Plan to pay for the services. You say that you were instructed to take these medications so that 
you could be released. The Plan denied your request. The Plan says this is not a 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 pay for self-administered drugs received 
on October 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stem cell harvest (38206) and storage (38207). 
 
You asked the Plan to pre-approve stem cell harvest and storage. You say that the service at issue is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the 
requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that when bone marrow or peripheral blood stem cell 
transplantation is covered all necessary steps are included in 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 stem cell harvest and storage. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that, for patients with advanced mantle cell lymphoma with complete response after 
initial treatment, consolidation therapy with autologous stem cell transplant is recommended. In this case, the 
enrollee's course was complicated by pneumonia related to COVID-19 and the plan would be to transplant in 1 
to 2 months. It is necessary to collect stem cells while in remission given high risk of relapse. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stem cell harvest and storage have been met. Therefore, we decided that the 
Plan has to pre-approve stem cell harvest (38206) and storage (38207).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the 
rehabilitation needs can be safely met in an alternate and lower intensity 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 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 Treanda. 
 
You asked the Plan to pre-approve Treanda. You say that the requested Treanda is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Bendeka and/or Belrapzo. 
 
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 Treanda. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has Waldenstrom macroglobulinemia. The requested medication is a new start. 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. 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 Treanda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Treanda.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia (J0129). 
 
You asked the Plan to pre-approve Orencia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed one of the preferred drugs, Remicade, 
infliximab, Inflectra, or Simponi Aria. 
 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 Orencia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not show 
that the enrollee has tried and failed any of the preferred drugs, Remicade, Infliximab, Inflectra, or Simponi 
Aria. The reviewer also found that the documentation does not support that Remicade, infliximab, Inflectra, or 
Simponi Aria would likely be less effective, and/or would likely have adverse effects for the enrollee in this 
case. 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 Orencia have not been met. Specifically, the file does not show that the enrollee 
has tried and failed the preferred drugs. Therefore, we decided that the Plan does not have to pre-approve 
Orencia (J0129).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (K0806). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that this is medically necessary for you 
to go out into the community and reach medical appointments. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (K0806).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization services provided from May 4, 2021, to 
May 5, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says a device code 
was not reported on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. In this case, the CPT Code Manual definition of code A9270 is on-covered 
item or service. We find that CPT code A9270 is not covered by Medicare. 
 
The File shows that CPT codes 37221 and 37236 were billed. We asked our coder 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 reviewer found that the enrollee underwent infrarenal abdominal aorta covered stent 
implantation, right common iliac artery covered stent implantation, and left common iliac artery covered stent 
implantation on May 4, 2021. The submission of a device-intensive procedure requires that a device be 
submitted on the same claim/day. The device codes are dated May 5, 2021. The device-intensive procedure 
code is reported without a device code on the same date of service. 
 
We looked at this coder's review, the file, and Medicare rules. 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 revascularization services provided from May 4, 2021, to May 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic (J3490). 
 
You asked the Plan to pre-approve Ozempic. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 Ozempic (J3490).  
 Benefits for Ozempic 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituximab (J9312). 
 
You asked the Plan to pre-approve Rituximab. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the medication requested is not appropriate for your condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Rituximab. Our reviewer says that the 
requested drug, Rituximab, is not medically necessary. Our physician reviewer found the provided 
documenation indicates that the enrollee has a diagnosis of refractory organizing pneumonia following 
treatment of breast cancer. The Food and Drug Administration (FDA) has not stated that the requested drug is 
indicated for the enrollee's condition. The reviewer found that the Medicare approved cancer drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
Therefore, the reviewer found that the requested drug Rituximab 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 Rituximab have not been met. Specifically, the file does not indicate that the 
requested drug is approved by the FDA for the enrollee's condition. Therefore, we decided that the Plan does 
not have to pre-approve Rituximab (J9312).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (procedure code 70450) provided to the 
enrollee on September 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for radiology services (procedure code 70450) provided to the 
enrollee on September 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ambrisentan, 5 mg tablet. 
 
You asked the Plan to pre-approve Ambrisentan. You say that the requested medication is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 Ambrisentan, 5 mg tablet.  
 Benefits for Ambrisentan 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation therapy (97014) provided on October 
6, 2021. 
 
You asked the Plan to pay for the electric stimulation therapy (97014). You say that you had physical therapy 
orders from an MD but chose a DC because of previous experience with a better outcome. You say that this 
treatment was less expensive than physical therapy. The Plan denied your request. The Plan says the 
chiropractic manipulative treatment (98941) has been approved. The electric stimulation therapy remains 
denied as chiropractic services other than manipulative treatment are not covered. 
 
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 the electric stimulation therapy (97014) provided on October 6, 2021.