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

 
We decided that the Plan does not have to pre-approve use of Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of triamcinolone acetonide before it will approve 
Zilretta. 
 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 Zilretta. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Zilretta. Our physician reviewer 
found the record does not show that the enrollee has tried and failed the Plan's preferred drug of triamcinolone 
acetonide. The record does not show that this drug would likely be less effective and/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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest-home visit (99335) provided on November 1, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the facility where the 
enrollee resides is responsible for obtaining necessary authorizations. You also say that the service was 
provided to the enrollee in good faith. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the rest-home visit (99335) provided on November 1, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99223. 
 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 99497 
is a column II code to column I code 99223. 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 procedure code 99497 billed for date of service April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on November 4, 2021, to 
November 7, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for inpatient services at the DRG originally billed. You say that these services were 
reported appropriately and are supported as billed. The Plan denied your request. The Plan says that the DRG 
submitted on this claim is not supported by the medical records provided, as the records do not support the 
diagnosis of acute kidney failure, unspecified (N17.9). 
 
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 did not provide any of the medical records for this 
admission which were used to make their decision. Without the medical records for this inpatient care, we 
cannot confirm whether or not the Plans denial is appropriate. Therefore, we decided that the Plan has to pay 
for inpatient hospital services provided on November 4, 2021, to November 7, 2021, at the Diagnosis Related 
Group (DRG) originally billed.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Procrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from June 30, 2022, to July 29, 
2022. 
 
You asked the Plan to pay for home health care. You say that you are requesting payment. The Plan denied 
your request. The Plan says the NOA has not been received by the Plan. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 30, 2022. The NOA was not received by the Plan at the time of their 
decision on October 28, 2022. As more than 30 days passed between the timely filing date and the NOA 
receipt, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for 
home health care provided from June 30, 2022, to July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and accessories 
(K0108, K0040x2, E0951x2, E0973x2, E0971x2, E2601, E2611). 
 
You asked the Plan to pre-approve an ultralightweight wheelchair and accessories. You say that you disagree 
with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a new 
wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a manual wheelchair. The records do not show that the enrollees current 
wheelchair no longer meets his needs, his current wheelchair cannot be repaired to meet his needs or that 
replacing or repairing parts on his current wheelchair costs more than a new wheelchair. A manual wheelchair 
serves the same purpose as an ultralightweight wheelchair and accessories. Therefore, we decided that the Plan 
does not have to pre-approve an ultralightweight wheelchair (K0005) and accessories (K0108, K0040x2, 
E0951x2, E0973x2, E0971x2, E2601, E2611).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G device. You say that you disagree with the denial and 
have submitted documentation to show medical necessity. The Plan denied your request. The Plan says the 
request is not accepted by medical standards. It has not been proved to be safe and effective to treat your 
condition. 
 
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 a MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested device is used for the upper extremity. It is an arm brace that 
is motorized and can help an individual with upper extremity weakness to move their arm and hand. The 
requested device has not been shown to be superior to other standard treatments for the medical condition. The 
studies do not indicate the MyoPro brace improves an individuals function or general health. The requested 
device 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 a MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, 
finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nulojix to be used in combination with Tacrolimus. 
 
You asked the Plan to pre-approve Nulojix. The Plan denied your request. The Plan says the use of this 
drug/regimen is not reasonable and necessary. The Plan also says the Medicare Part B compendia and 
authoritative medical journals do not support the use of Nulojix in combination with Tacrolimus for treatment 
of the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Nulojix. Our reviewer says that Nulojix 
to be used in combination with Tacrolimus is not reasonable and necessary for the enrollee. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of renal transplant recipient status in 
January 2022. The record indicates that the enrollee received thymoglobulin induction and is receiving 
Tacrolimus. Our reviewer found that the FDA has not stated that the requested drug as prescribed is indicated 
for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the 
use of the requested drug as prescribed in the enrollee's clinical situation. Our physician reviewer also found 
that the elements of the coverage criteria are not satisfied, and 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 Nulojix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nulojix to be used in combination with Tacrolimus.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a E-Wheels SpinLife M45 Lightweight folding electric 
wheelchair. 
 
You asked the Plan to pre-approve a E-Wheels SpinLife M45 Lightweight folding electric wheelchair. You say 
that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-
preferred brands). 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a E-Wheels SpinLife M45 Lightweight 
folding electric wheelchair. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found in this case, the documentation available for review does not indicate the brand-named device 
improves an individuals overall function or general health more than the other standard equipment or treatments provided by the health plan. Additionally, the documentation available for review does not support 
the medical necessity for a power mobility device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a E-Wheels SpinLife M45 Lightweight folding electric wheelchair have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a E-Wheels SpinLife M45 
Lightweight folding electric wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bronchoscopy with bronchial thermoplasty. 
 
You asked the Plan to pre-approve a bronchoscopy with bronchial thermoplasty. You say that a bronchoscopy 
with bronchial thermoplasty is medically necessary. The Plan denied your request. The Plan says a 
bronchoscopy with bronchial thermoplasty is experimental/investigational. 
 
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 a bronchoscopy with bronchial 
thermoplasty. Our reviewer says that the requested bronchoscopy with bronchial thermoplasty is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrolee has severe asthma 
and is being treated with bronchodilators and inhaled steroids as well as pulmonary rehabilitation to help 
control symptoms. A review of currently available evidence on bronchial thermoplasty was made and found to 
be limited with limited benefit and some added increased risk without enough information on longer-term 
benefit and risk. It will be considered investigational due to the insufficient high-quality evidence to support its 
regular use over standard treatment methods. Therefore, it will be considered not medically necessary in this 
case at this time.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bronchoscopy with bronchial thermoplasty have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a bronchoscopy with bronchial thermoplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer (codes 96365 and J1756). 
 
You asked the Plan to pre-approve Venofer. The Plan denied your request. The Plan says the use of this drug 
for the enrollee's illness is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Venofer. Our reviewer says that 
Venofer is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of breast cancer and reported iron deficiency anemia. The record 
provided does not document the presence of anemia or iron deficiency, or that the enrollee is intolerant to, or 
has failed, oral iron. Our reviewer found that the FDA has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Our physician reviewer also found that the elements of the 
coverage criteria are not satisfied, and 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 Venofer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Venofer (codes 96365 and J1756).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81000, 82570, G0483) provided on March 29, 
2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical records. 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, for 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 (81000, 82570, G0483) provided on March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart pulse generator. 
 
You asked the Plan to pre-approve an Optimizer Smart pulse generator. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 an Optimizer Smart pulse generator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found while clinical studies led to FDA approval in 2019, cardiac 
contractility modulations (CCM) remain the subject of multiple studies examining long-term efficacy, as well 
as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, a CCM 
system is not thought to be medically necessary for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer Smart pulse generator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an Optimizer Smart pulse generator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 2, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
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 procedure code 70450 billed for date of service October 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on March 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided on March 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Armodafinil. 
 
You asked the Plan to pre-approve Armodavinil. You say that this drug is important to your regimen that helps 
you to function more normally on a daily basis. The Plan denied your request. The Plan 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 Armodafinil.  
 
Benefits for Armodavinil may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.