Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an amyloid positron emission tomography (PET) scan 
 
You asked the Plan to pre-approve an amyloid PET scan. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide us with medical records. The case file 
shows that the enrollees representative in this appeal is their treating provider who is contracted with the Plan. 
Participating network providers are considered agents of the Plan. It is the responsibility of the Plan to obtain 
documentation from their network providers that is necessary for us to make a determination regarding their 
denial. Without medical records, we are unable to make a determination regarding the Plans denial reason that 
the requested services are not medically necessary. Therefore, we decided that the Plan has to pre-approve an 
amyloid positron emission tomography (PET) scan  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block provided on August 2, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of a genicular nerve block in the setting of knee 
osteoarthritis have not been demonstrated in the peer-reviewed literature. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this is considered an experimental therapy. It 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a genicular nerve block provided on August 2, 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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. 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 physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza. 
 You asked the Plan to pre-approve Qutenza. You say that gabapentin is not effective in controlling pain. The 
Plan denied your request. The Plan says before this drug is covered, the enrollee must try lidocaine 5% patch 
(also requires approval before it is covered) and 1 of the following: duloxetine, venlafaxine, pregabalin, 
gabapentin, or a tricyclic antidepressant (such as amitriptyline). The Plan also says that information from the 
provider shows the enrollee has tried gabapentin, but the enrollee has not tried lidocaine 5% patch.  
 
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 Qutenza. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the provided coverage criteria 
require that the enrollee try lidocaine patches for control of the neuropathy pain before the requested 
medication can be approved; there is no data given to indicate that this medication has been tried or that it is 
contraindicated. Hence, coverage criteria for Qutenza are not met 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 Qutenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Qutenza.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical and occupational therapy to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve physical and occupational therapy. You say that the requested provider is 
more accessible to you. The Plan denied your request. The Plan says these services are available in-network. 
 
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 
physical and occupational therapy to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ciltacabtagene autoleucel (CAR T-cell therapy). 
 
You asked the Plan to pay for ciltacabtagene autoleucel (CAR T-cell therapy). The Plan denied your request. 
The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Chimeric Antigen Receptor (CAR) T-cell Therapy is 
covered for the indications established in the applicable NCD. 
 
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 pay for ciltacabtagene autoleucel (CAR T-cell 
therapy). Our reviewer says that the requested ciltacabtagene autoleucel is not medically reasonable and 
necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the ciltacabtagene Autoleucel chimeric antigen receptor (CAR) T-cell therapy at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for the enrollee. The provided records do not 
document the enrollee has a cancer with T-cells expressing at least one chimeric antigen receptor (CAR) as 
required by the National Coverage Determination (NCD) Chimeric Antigen Receptor (CAR) T-cell Therapy 
110.24.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ciltacabtagene autoleucel (CAR T-cell therapy) have not been met. Therefore, 
we decided that the Plan does not have to pay for ciltacabtagene autoleucel (CAR T-cell therapy).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve code E2310. You say that when one power seating function/actuator/motor 
is provided on a power wheelchair, one unit of E2310 is allowed. The Plan denied your request. The Plan says 
the electronic connection cannot be covered as it is not medically necessary to control the two power options 
through the joystick (drive interface). 
 
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 code E2310. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has rigid spine muscular dystrophy and impaired ambulation. He drives himself, and using a power wheelchair is independent in feeding, dressing, grooming and toileting. The enrollee has sufficient 
strength and function in upper extremities to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code E2310 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection between wheelchair controller and one power seating system 
motor (E2310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation and management (E&M) service (99291) 
provided on March 26, 2023. 
 
You asked the Plan to pay for 99291. You say that the coding was correct. The Plan denied your request. The 
Plan says this service was performed on the same day as major surgery 49002 and is not supported for separate 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -24 must be supported by 
documentation to establish that the visit was unrelated to the surgery which imposed a global period on the date 
of service.  
 We looked at the file and Medicare rules. The documentation submitted explicitly references the surgery 
performed on this date of service (code 49002); therefore, it cannot be said that the documentation establishes 
this E&M service as unrelated to the surgery. Based on this information, we decided that Medicare rules for 
coverage of 99291 have not been met. Therefore, we decided that the Plan does not have to pay for an 
evaluation and management (E&M) service (99291) provided on March 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way trips. 
 
You asked the Plan to pre-approve additional one-way trips. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your transportation benefit has been exhausted. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one-way trips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing visits x1 and physical therapy home 
health visits x3. 
 You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not require additional skilled nursing or rehabilitation services to effectively provide treatment, care, 
and/or services to improve the enrollees 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the skilled nursing visits x1 and physical therapy home health visits x3.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the unlisted molecular pathology procedure (81479) provided March 
24, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that attached you will find supporting 
documentation substantiating medical necessity. The Plan denied your request. The Plan says that the records 
do not support that the criteria has been met. 
 
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 pay for the laboratory testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this test serves to detect rejection before it is clinically apparent. It is indicated. Rejection will 
significantly reduce the life of function of a transplant. This test is indicated to screen for early rejection that 
may not otherwise be clinically apparent. This test meets the following criteria: the intended use of the test 
must be: To assist in the evaluation of adequacy of immunosuppression, wherein a non-invasive or minimally 
invasive test can be used in lieu of a tissue biopsy in a patient for whom information from a tissue biopsy 
would be used to make a management decision regarding immunosuppression. 
 
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 laboratory testing have been met. Therefore, we decided that the Plan has to 
pay for the unlisted molecular pathology procedure (81479) provided March 24, 2023.  
 
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: 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 the requested SNF services are medically necessary, 
there are realistic goals with measurable improvement, and the enrollee's care needs cannot be met at home.  
The Plan denied your request. The Plan says transfer to a SNF for inpatient skilled rehabilitation services 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: 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 is recovering from an amputation and 
they require early and aggressive rehab in order to regain function status as soon as possible. They are at risk of 
falls, sores, and further deconditioning with potential for acute illness, re-injury, and readmission to the 
hospital. The Plan denied your request. The Plan says the inpatient rehabilitation facility (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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. 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 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. 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.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. You say that Eylea is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Eylea have 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 Eylea. Our reviewer says that treatment 
with Eylea is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of Byooviz before they will approve the requested drug. The requested drug 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Eylea (J0178).