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

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not trialed and failed the preferred medication Infed (iron 
dextran). 
 
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 Feraheme. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
iron deficiency anemia. 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 
Infed (iron dextran). The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 3, 2021, billed 
with procedure code 99213-25. 
 
You asked the Plan to pay for the services. You say that the claim was billed correctly. The Plan denied your 
request. The Plan says the code is not 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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the enrollee only came into the wound 
care clinic for wound care, and no separately identifiable evaluation was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on December 3, 2021, billed with procedure code 99213-25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wrist manipulation under anesthesia. 
 
You asked the Plan to pre-approve wrist manipulation under anesthesia. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the requested service is 
considered experimental, investigational or unproven. 
 
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 wrist manipulation under anesthesia. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the detailed documentation is not evident regarding a significantly 
objectively decreased range of motion in the right wrist. Additionally, x-rays are noted to show well-positioned 
hardware and maintenance of length, alignment, and rotation of the fracture with interval healing is noted. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wrist manipulation under anesthesia have not been met. Therefore, we decided 
that the Plan does not have to pre-approve wrist manipulation under anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20610-78 rendered on July 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the left knee steroid injection was performed in the office; therefore, it is included in the global 
surgical package of CPT 29880. 
 
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 20610 is ""Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records describe that 
the enrollee had a procedure performed on the left knee, which has a global day period of 90 days. The enrollee 
presented to the office for left knee pain, and an injection was given during the post-operative period. In this 
case, the modifier billed in this case cannot be verified, as the enrollee did not return to the operating/procedure 
room. The enrollee presented to the office. A procedure performed in the office that was not related to the 
primary procedure was not documented, therefore the left knee injection would be included in the global 
period. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 20610-78 rendered on July 12, 2023.
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 would benefit from an IRF admission. 
The Plan denied your request. The Plan says the IRF services requested 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 the enrollee does 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 multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with single power option (tilt) and 
accessories (K0856, E0953, E0955, E0960, E1002, E1028, E2359, E2620, E2622). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the records do not show a medical 
need for the requested power option. 
 The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 a power wheelchair and accessories. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a power wheelchair with tilt option. She has severe 
impaired mobility and requires a Hoyer lift for transfer. She has caregiver assistance days and evenings. She 
has a right upper extremity with 3-/5 strength. She has intact skin. Per L33789, the enrollee does not have skin 
injury, but her current chair has the power tilt option, a reasonable means of preventing skin breakdown. 
Criteria for a single power option is met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have been met. Therefore, we decided that 
the Plan has to pre-approve a group 3 power wheelchair with single power option (tilt) and accessories (K0856, 
E0953, E0955, E0960, E1002, E1028, E2359, E2620, E2622).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with volume 
assurance. The records do not show this has been tried as an outpatient. There is no evidence in the medical 
record that the enrollee would require pressures or flow rates not achievable with BiPAP.  Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78608).  
 
You asked the Plan to pre-approve the PET scan. You say that the services are necessary. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found in this case the enrollee is noted to have a 
history of a cognitive impairment. However, there was no indication that she met the diagnostic criteria for 
either, let alone both AD and FTD. Rather she was only noted to possibly have AD. Given that the enrollee 
does not otherwise meet the baseline requirements of the NCD for coverage of this service, it would not be 
considered 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan (78608).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve the medication. You say that the drug should be covered under Medicare 
Part D. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 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 Gamunex-C.  
 
Benefits for the medication 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care is not sufficient or safe to 
provide the enrollee the ample services needed for optimal recovery. The Plan denied your request. The Plan 
says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve the requested services. You say that behavioral services are needed. The 
Plan denied your request. The Plan says the services needed can be provided safely in other settings.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 Continued inpatient services from December 28, 2023, forward, were requested. 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 services. Our physician reviewer found that the 
enrollee was admitted to the acute inpatient psychiatric hospitalization on December 22, 2023, with major 
neurocognitive disorder, most likely due to Alzheimers disease with behavioral disturbance. Based upon 
review the records provided it was not expected this enrollee would improve in a reasonable period of time 
beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. Therefore, the 
requested services are 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart muscle strain imaging. 
 
You asked the Plan to pre-approve heart muscle strain imaging. 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 heart muscle strain imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient support in the peer-reviewed literature demonstrating a 
significant benefit of such imaging of the heart in guiding optimal management of this enrollee. As such, 
myocardial strain imaging is considered experimental/investigational for the evaluation and management of this enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of heart muscle strain imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve heart muscle strain imaging.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve three-dimensional (3D) rendering for magnetic resonance imaging 
(MRI). 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has memory loss with no 
significant improvement. The Plan denied your request. The Plan says that the service is considered 
investigational and experimental.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the requested services. Our physician 
reviewer found that the enrollee has progressive memory loss. The Montreal Cognitive Assessment (MoCA) 
score was abnormal at 18/30 with normal labs. An MRI of the brain was ordered to include 3D volumetric 
analysis (Neuroquant). The requested 3D rendering of the ordered MRI of the brain is reasonable based upon 
lab values, cognitive testing and history. Such volumetric analysis is standard practice to evaluate the volume 
of the temporal lobes and hippocampus. Such analysis is valuable in making the diagnosis.  
 
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 services have been met. Therefore, we decided that the Plan has to 
pre-approve three-dimensional (3D) rendering for magnetic resonance imaging (MRI).  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the arm joint. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that the documentation does not show the criteria is met for the requested MRI.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found with history of the left shoulder dislocation and the 
left upper extremity weakness; this constitutes a red flag. The requested MRI of the left shoulder should be 
approved. 
 
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 MRI have not been met. Therefore, we decided that the Plan has to pre-
approve a magnetic resonance imaging (MRI) of the arm joint.  
 
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.