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

 
We decided that the Plan does not have to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that the patient has tried multiple other medications that 
have not helped. The Plan denied your request. The Plan says this drug is not covered under the patient's 
medical benefits. 
 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 Spravato.  
 
Benefits for Spravato 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise bike. 
 
You asked the Plan to pre-approve an exercise bike. You say that you have a severe breathing problem. You 
say that you cannot exercise. You say that you were approved for a scooter a year ago. You also say that if you 
had this bike then you could exercise all day and at night. The Plan denied your request. The Plan says the 
requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an exercise bike.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation, revision or repositioning of tunneled 
intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable 
reservoir/infusion pump (62350) implantation or replacement of device for intrathecal or epidural drug 
infusion; programmable pump, including preparation of pump, with or without programming (62362). 
 
You asked the Plan to pre-approve the implantable pain pump. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says the records do not support that 
medical necessity has been established. 
 
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 implantable pain pump. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a surgical consultation. It is not clear from the 
documentation that the enrollee has had a full 6-month trial of conservative therapy. At this point, the enrollee 
does not meet the criteria and therefore, the request is deemed not medically reasonable and 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 the implantable pain pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantation, revision or repositioning of tunneled intrathecal or epidural 
catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump 
(62350) implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, 
including preparation of pump, with or without programming (62362).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level (code 22869). 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar, single 
level. You say that insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar, single level is medically 
necessary. The Plan denied your request. The Plan says the requested insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level is not medically necessary. 
 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 insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level. Our reviewer says that the requested insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that interlaminar devices are experimental in spine surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar, single level have 
not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, 
including image guidance when performed, lumbar, single level (code 22869).
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 you need to get stronger to return home. The Plan 
denied your request. The Plan says your ongoing skilled care can be provided in an alternative setting such as a 
skilled nursing facility. 
 
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 treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral orbilateral injection, with fluoroscopic guidance, lumbar; 
first level (code 06327T). 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral orbilateral injection, with fluoroscopic guidance, lumbar; first level. You say that 
percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral 
orbilateral injection, with fluoroscopic guidance, lumbar; first level is medically necessary. The Plan denied 
your request. The Plan says percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral orbilateral injection, with fluoroscopic guidance, lumbar; first level is not 
medically necessary. 
 
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 percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral orbilateral injection, with fluoroscopic 
guidance, lumbar; first level. Our reviewer says that the requested percutaneous injection of allogeneic cellular 
and/or tissue-based product, intervertebral disc, unilateral orbilateral injection, with fluoroscopic guidance, 
lumbar; first level is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is an experimental/investigational procedure, which is the subject of ongoing clinical trials. 
Therefore, the request is deemed not medically reasonable and 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 percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral orbilateral injection, with fluoroscopic guidance, lumbar; first level have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral orbilateral injection, with fluoroscopic 
guidance, lumbar; first level (code 06327T).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the enrollee is well controlled with Ilumya. The Plan 
denied your request. The Plan says that the enrollee has not failed two of the Plan's preferred drugs. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our physician reviewer found 
that step therapy is the process of beginning drug therapy for a medical condition with "preferred" (or more 
cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. In 
this case, the record indicates that the enrollee has moderate to severe plaque psoriasis. The requested 
medication is not a new start as the record indicates that the enrollee has been receiving the requested drug 
since August 2022. The elements of the coverage criteria are satisfied. The requested service is 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 Ilumya have been met. Therefore, we decided that the Plan has to pre-approve 
Ilumya.  
 
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 Fulphila. 
 You asked the Plan to pre-approve Fulphila. 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 Fulphila. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Neulasta and Udenyca. The documentation does not support that Neulasta 
and Udenyca would likely be less effective, and/or would 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 Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
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 enrollee will benefit from the services received at 
this level of care. The Plan denied your request. The Plan says the enrollee does not need an intensive team for 
their care needs. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the F2 (prothrombin, coagulation factor II) (eg, 
hereditary hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation Factor V) (eg, 
hereditary hypercoagulability) gene analysis, Leiden variant (81241). 
 You asked the Plan to pre-approve the genetic testing. You say that please review attached clinicals regarding 
genetic testing. The Plan denied your request. The Plan says the records do not support that medical necessity 
has been established. 
 
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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found testing for Gene Analysis: F2 (prothrombin, coagulation factor II) and F5 
(coagulation Factor V) Leiden variant is indicated for patients less than 45 years of age, family history or other 
high-risk factors. This enrollee has a below knee deep vein thrombosis and is in the 70s. Testing is unlikely to 
impact the enrollees management. The service is not reasonable or 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene 
analysis, 20210G>A variant (81240) and F5 (coagulation Factor V) (eg, hereditary hypercoagulability) gene 
analysis, Leiden variant (81241).
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 you would lose more function without this care. The 
Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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 treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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 pay for physician services (99220) provided on July 5, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 99220 is evaluation and management of a patient, 
requiring a comprehensive examination; and Medical decision making of high complexity. 
 
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 physician services. Our reviewer says that the 
documentation does not support the billed services. Our reviewer found based on the provided documentation 
there was insufficient history and physical documentation to be considered comprehensive, and the decision-making was not highly complex. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99220) provided on July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser assisted cataract surgery. 
 
You asked the Plan to pre-approve the surgical procedure. You say that laser assisted surgery is safer than the 
manual method. The Plan denied your request. The Plan says while cataract surgery is covered, the laser 
portion is not covered by Medicare, as it considers it more of a convenience procedure 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found laser technology does not qualify as a covered benefit as defined under Medicare 
guidelines. There is no scientific information or research that shows its long-term effectiveness and 
improvement on outcomes in treating cataract surgery. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laser assisted cataract surgery.