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

We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550, 83970
and 84100) provided on June 9, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the Centers for Medicare and Medicaid
Services allows only dialysis facilities to report ESRD-related laboratory tests and includes reimbursement for
laboratory testing in dialysis.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate.
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for
the laboratory services (82310, 82728, 83540, 83550, 83970 and 84100) provided on June 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60MG/ML syringe.
You asked the Plan to pre-approve the medication. You say that the enrollee has osteoporosis and has been
prescribed Prolia injection 60MG syringe. You state the enrollee cannot take oral medication because they had
bariatric surgery in October 2018, and it will damage the enrollee's stomach to take this medication orally. The
Plan denied your request. The Plan says the practitioner did not document that the enrollee meets the criteria.
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 medication. Our physician reviewer
found the case file does not contain documentation of trial and failure of an intravenous bisphosphonate. The
documentation does not support that an intravenous bisphosphonate would likely be less effective, and/or
would likely have adverse effects for the enrollee 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 the medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prolia 60MG/ML syringe.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra drops.
You asked the Plan to pre-approve Xiidra drops. You say that you would like reconsideration because the
requested drug is medically necessary. 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 selfadministered
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 Xiidra drops.
Benefits for Xiidra drops may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that her ongoing care warrants this level of
care to achieve safe and sustainable discharge. The Plan denied your request. The Plan says appropriate care is
being received in the hospital.
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 was currently undergoing treatment at an acute care hospital (LTACH)
for COVID-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services
that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is
no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long term care needs.
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 pre-approve services related to a clinical trial.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
services are covered by Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve services as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to preapprove
services related to a clinical trial.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a minimally invasive Image-Guided Lumbar
Decompression (MILD) procedure (0275T).
You asked the Plan to pre-approve the MILD procedure.. You say that the services are medically necessary.
The Plan denied your request. The Plan says this procedure is non-covered unless part of an approved clinical
trial.
The Plan must follow Medicare rules. Medicare rules say that Minimally invasive Image-Guided Lumbar
Decompression (MILD) is only covered in cases where the patient is enrolled in a clinical trial for the
collection of data.
We looked at the file and Medicare rules. The record does not show that the enrollee is part of a clinical trial.
Based on this information, we decided that Medicare rules for coverage of the MILD procedure. have not been
met. Therefore, we decided that the Plan does not have to pre-approve a minimally invasive Image-Guided
Lumbar Decompression (MILD) procedure (0275T).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve a PET scan. You say that this is medically necessary as a diagnostic service. The Plan denied your request. The Plan says this is not covered per Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that a PET scan is non-covered for testing for a diagnosis of dementia of Lewy bodies. We looked at the file and Medicare rules. This imaging service is specifically requested for testing for a diagnosis of dementia of Lewy bodies. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on July 21, 2021.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says you must
receive eyewear from an in-network provider.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when obtained from a provider in the Plan's vision vendor network.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not obtained from a provider
in the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of
the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for
eyeglasses provided on July 21, 2021.
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 does not meet
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 you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your
care needs can be met at a lower level of care such as in a skilled nursing facility.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 17 additional fractions of radiation therapy for the
enrollee.
You asked the Plan to pre-approve the additional fractions. You say that this is medically necessary. The Plan
denied your request. The Plan says the request for more than 28 doses exceeds the limit.
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 additional fractions. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found 20 to 28 fractions of intensity-modulated radiation therapy are considered medically
necessary for treatment of low risk prostate cancer in up two phases. The enrollee does not need more than 28
doses.
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 additional fractions have not been met. Therefore, we decided that the Plan
does not have to pre-approve 17 additional fractions of radiation therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional month using a negative pressure wound
therapy (NPWT) electrical pump (E2402).
You asked the Plan to pre-approve an additional month using a NPWT electrical pump. You say that you
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has
been using a NPWT electrical pump for over 4 months. Medicare only covers the use of this item for up to 4
months.
The Plan must follow Medicare rules. Medicare rules say that negative pressure wound therapy pumps are
covered for up to four months.
The file shows that treatment has lasted for four months at this point. This pump cannot be covered past four
months of use. Based on this information, we decided that Medicare rules for coverage of an additional month
using a NPWT electrical pump have not been met. Therefore, we decided that the Plan does not have to pre-
approve an additional month using a negative pressure wound therapy (NPWT) electrical pump (E2402).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the enrollee is in extreme pain. The Plan denied your request. The Plan says there was not significant improvement following the prior injection series.
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 Euflexxa. Our physician reviewer found that the enrollee has bilateral knee osteoarthritis. She has had intra-articular steroid injections and had a prior viscosupplementation in the right knee with only minimal brief relief. The request is to repeat the injection. The enrollee failed to achieve sustained significant pain relief from the prior injection. Therefore, the request is considered 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 you remain on a ventilator. It is unclear if ventilator liberation or decannulation are
achievable. As LTACHs and acute care hospitals (ACH) are licensed to provide the same level of care, there is
no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute
services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term
care needs.
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology gene expression profiling coded 0012M
provided on August 10, 2021.
You asked the Plan to pay for the oncology gene expression profiling. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that the testing identified with code 0012M is noncovered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oncology gene expression profiling have not been met. Therefore, we decided that the Plan does not have to pay for the oncology gene expression profiling coded 0012M provided on August 10, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance (ALS or BLS) oxygen and oxygen supplies, life
sustaining situation (A0422) provided on April 1, 2021.
You asked the Plan to pay for ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation
(A0422). The Plan denied your request. The Plan says suppliers are paid at a base rate to include supplies with
milage allowed separately.
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen,
is included in the fee schedule payment.
We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen,
is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for
ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation (A0422) provided on
April 1, 2021.
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 is not medically necessary.  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 admission to a LTACH is not medically necessary. Our physician reviewer found the review indicates that the member been hospitalized due to complications from heart surgery. He sustained significant anoxic brain damage and has required mechanical ventilation via a tracheostomy. The most recent medical documentation states he has very recently required intravenous sedation to treat agitation and tachypnea. His providers have also stated his bowel function has been slow to return and are planning to start PEG feeding tube feedings and adjust as needed. 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 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.  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 treatment with Dulera Aer.
You asked the Plan to pre-approve Dulera Aer. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Dulera Aer.
Benefits for Dulera Aer 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 the 30mg Armour Thyro Tablets.
You asked the Plan to pre-approve the Armour Thyro Tablets. You say that you would like reconsideration because the requested drug is medically necessary. 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 the 30mg Armour Thyro Tablets.
Benefits for the Armour Thyro Tablets 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 Eliquis.
You asked the Plan to pre-approve Eliquis. You say that the drug is medically necessary for the enrollee. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.
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 Eliquis.
Benefits for Eliquis 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 Aduhelm infusions (J3590).
You asked the Plan to pre-approve Aduhelm infusions. You say that at this time there are no other treatment options. The Plan denied your request. The Plan says the requested infusions 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 Aduhelm infusions. Our reviewer says that Aduhelm infusions are not medically necessary. Our physician reviewer found the provided documentation does not support that the requested Aduhelm infusions are medically reasonable and necessary for the enrollee in this case. The reviewer also found that the provided documentation does not support that the Aduhelm infusions would be safe and effective 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 Aduhelm infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm infusions (J3590).