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

 
We decided that the Plan does not have to pre-approve Genvisc 850. 
 
You asked the Plan to pre-approve Genvisc 850. 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 Genvisc 850. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse 
effects 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 Genvisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Genvisc 850.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is 
walking household distances with a rolling walker with contact guard assistance and is stand-by assist for 
transfers. Provided records do not document a significant decline in the enrollees functional status to 
necessitate further daily inpatient skilled therapy services. The enrollee does not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the home 
with home health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on April 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit of this 
code is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that an additional unit of CPT code 99233 is not supported in the medical record. Specifically, the 
records show that only one unit of code 99233 was provided on the date of service in question. This was 
previously processed and paid by the Plan. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (99233) provided on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network medical center. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network medical center.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and should only require short-term additional 
acute care hospital services that can be safely completed at the current facility until appropriate for a lower 
level of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 21, 2021 by an out-of-
network (OON) hospital. 
 
You asked the Plan to pay for the OON labs. You say that you didn't know that your doctor was going to send 
your labs to this out-of-network hospital. The Plan denied your request. The Plan says unauthorized, non-plan 
services are not covered. 
 
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 hospital in this case is not a network provider with the Plan. In addition, the provider who referred you to 
the hospital for these lab services is also 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 lab services provided on December 21, 2021 by an 
out-of-network (OON) hospital.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 9, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the testing was not 
ordered/approved by the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The records do not show that the lab services were ordered by the 
physician who is treating the enrollee in this case. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara airway clearance system (E1399, A9999). 
 
You asked the Plan to pre-approve the Volara airway clearance system. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the Volara airway clearance system. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient evidence that this device if effective in the treatment of the 
enrollee's condition. With regard to airway clearance, It has not been directly compared with high-frequency 
chest wall oscillation. The medical records do not address the need for airway clearance therapy, or this device 
specifically. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Volara airway clearance system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Volara airway clearance system (E1399, A9999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH will provide the 
individualized and aggressive treatment needed. The Plan denied your request. The Plan says LTACH care is 
not medically necessary. The Plan says that the enrollee's needs can be met at an alternative level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara (ustekinumab) treatments. 
 
You asked the Plan to pre-approve the Stelara treatment. You say that it is felt that this should be allowed 
because anti-TNF medications would increase her risk of infection which is not appropriate given the enrollee's 
age. The Plan denied your request. The Plan says there is no documented failure to the preferred drugs, nor any 
reason they would be less effective.  
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 the Stelara treatment. Our reviewer says 
that the requested drug is not considered medically reasonable and necessary based on step therapy criteria. Our 
physician reviewer found the record indicates that the enrollee has Crohns disease. 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.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Stelara treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Stelara (ustekinumab) treatments.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, abdomen (74018) provided on 
August 29, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic service. You say that the enrollee is in a nursing home with whom 
you have an exclusive contract with. The enrollee is bed bound and services had to be performed STAT so 
there was no time to obtain authorization. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 radiologic examination, abdomen (74018) 
provided on August 29, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on November 9, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that this claim is not a duplicate and should be paid. The 
Plan denied your request. The Plan says this claim is a duplicate of another submission which has already been 
processed and paid. 
 The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be an exact duplicate are rejected and do not have appeal rights. An exact duplicate for institutional claims is 
a claim or claim line that exactly matches another claim or claim line with respect to certain elements. 
 
We looked at the file and Medicare rules. The documentation shows that the Plan has paid a previous claim for 
this service billed with the same CPT code and modifier by the same provider for the same enrollee on the 
same date of service. The documentation does not indicate that the enrollee had multiple abdominal ultrasounds 
on the date in question. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound 
(76705) provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide. 
 
You asked the Plan to pay for a stair glide. You say that you would like reconsideration because the stair lift 
was medically necessary due to your condition. The Plan denied your request. The Plan says this provider does 
not accept Medicare. 
 The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Additionally, the record indicates that this provider does not accept Medicare. Therefore, we decided that the 
Plan does not have to pay for a stair glide.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ipilimumab and nivolumab. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the combination of ipilimumab and 
nivolumab is Food and Drug Administration (FDA)-approved as second line therapy in hepatocellular cancer 
after treatment with sorafenib. This enrollee has not received prior therapy. Off-label use is not supported by 
major drug compendia or the medical literature. The service is not reasonable or medically necessary or likely 
to be safe or effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ipilimumab and nivolumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an above knee alignable system. 
 
You asked the Plan to pre-approve the requested item. You say that the requested system is an essential 
component of her preparatory prosthesis. The Plan denied your request. The Plan says the alignable system is 
not appropriate for use on a preparatory prosthesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested item. Our physician 
reviewer found that the enrollee has a diagnosis of acquired absence of right leg above knee. The enrollee has 
an approval for a preparatory prosthesis L5590 (Preparatory, above knee (AK), knee disarticulation, ischial 
level socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model). The 
preparatory prosthesis is a non-alignable system.  
 The enrollee is noted to be a K2 ambulator. The requested items exceed her medical need as the current 
approved preparatory prosthesis is non-alignable and at this time the alignable system is not appropriate for the 
patient's functional need. The request for the prosthetic component does not meet medical necessity criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an above knee alignable system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot for the enrollee. 
 
You asked the Plan to pre-approve Lupron Depot. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the 
preferred products. 
 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 Lupron Depot. Our reviewer says that 
Lupron Depot is not medically reasonable and necessary for the enrollee. The patient has not tried and failed 
Eligard. Eligard would not likely be less effective and/or likely have adverse effects for the enrollee as they are 
equivalent. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for 
Lupron Depot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural injection. 
 
You asked the Plan to pre-approve a lumbar epidural injection. 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 epidural steroid injections are covered when specific 
criteria are met. 
 
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 lumbar epidural injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found you do not have 
physical exam findings that support a diagnosis of radiculopathy. You have scoliosis, Epidural steroids are not 
indicated for the pain of scoliosis. The request 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 a lumbar epidural injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar epidural injection.