Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ClariFix. 
 
You asked the Plan to pre-approve ClariFix. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the requested service is considered investigative and 
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 ClariFix. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has chronic rhinitis and septal deviation. There is 
insufficient literature to support the safety and efficacy of the requested service for the enrollee's specific 
conditions. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ClariFix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ClariFix.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Herceptin. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Herceptin is not approved by the Food 
and Drug Administration (FDA) for the enrollee's diagnosis of metastatic human epidermal growth factor 
receptor two positive vulvar adenocarcinoma. The use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. Herceptin is not safe and effective and 
medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Herceptin.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services. 
 You asked the Plan to pre-approve home health services. You say that you would like to maintain the 
maximum function you have gained through the occupational therapy you have received these last few weeks. 
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 you do not 
have documented occupational therapy needs. As such, the requested home health occupational therapy 
services are not medically necessary or reasonable. 
 
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 home health care services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extreme lateral lumbar interbody fusion. 
 
You asked the Plan to pre-approve extreme lateral lumbar interbody fusion. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says you need to be free from 
using tobacco products for at least six weeks prior to your surgery. 
 
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 extreme lateral lumbar interbody 
fusion. 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 fracture instability or lesion. Fusion surgery 
not 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 extreme lateral lumbar interbody fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve extreme lateral lumbar interbody fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost liquid protein nutritional supplements. 
 
You asked the Plan to pre-approve these services. You say that the supplemental nutrition was requested by 
your doctor. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Boost liquid protein nutritional supplements.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the electronic connection . You say that the requested accessory is needed 
for the enrollee's condition. The Plan denied your request. The Plan says there is not a medical need to control 
the requested power options through the joystick. 
 
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 electronic connection. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has diabetes and a recent below knee amputation. He is independent with feeding 
and toileting. The enrollee has adequate strength 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 the electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors (E2311).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimerli. 
 You asked the Plan to pre-approve the druig. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy guidelines were not followed. 
 
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 druig. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the plan 
requires a trial of Byooviz before they will approve the requested drug. In this case, the patient has not tried 
and failed the required drug. There is no documentation provided indicating that the plan's required drug would 
likely be less effective and/or likely have adverse effects 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 the druig have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cimerli.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 F2 gene analysis and F5 gene analysis. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that F2 gene (prothrombin coagulation factor II) 
and F5 gene (coagulation factor V) The F2 and F5 genetic tests are not considered to be clinically efficacious; 
therefore, testing is not 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 F2 gene analysis and F5 gene analysis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found this testing is 
only covered for pregnant individuals if they otherwise meet LCD criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of F2 gene analysis and F5 gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve 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 pay for long term acute care hospital (LTACH) services provided on 
July 2, 2023, to July 19, 2023. 
 
You asked the Plan to pay for the LTACH services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
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 pay for the LTACH services. Our reviewer says that 
the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. 
The enrollee was receiving appropriate care at the present acute care hospital. The review has determined that the enrollee did not require services at the LTACH that were not available at the acute care hospital where the 
enrollee was currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pay for long term acute care hospital (LTACH) services provided on July 2, 2023, to July 19, 
2023.
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 LTACH services are medically 
necessary. The appellant says the enrollee needs oxygen which is not available at a lower level of care. The 
Plan denied your request. The Plan says the LTACH services are not medically necessary, and the enrollee's 
needs are being met in the current hospital facility. 
 
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 admitted for right lower lobe mass resection/right thoracotomy. 
There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) supplies 
from an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that you have been using this provider for the past 
six months. The Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) 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 continuous positive airway pressure (CPAP) 
supplies from an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
  You asked the Plan to pre-approve Gelsyn-3. You say that the patient has suffered from chronic progressive 
knee pain for over 6 months and has failed to respond to more conservative measures. You say that 
viscosupplementation is medically necessary and coverage for Gelsyn injections in both knees should be 
approved. The Plan denied your request. The Plan says the enrollee has not tried the 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 Gelsyn-3. Our reviewer says that the 
criteria for coverage has not been met. Our physician reviewer found the patient has not tried and failed the 
required drugs. There is no documentation indicating that the Plan's required drugs would likely be less 
effective or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tempus xF testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the test is not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
We looked at the file and Medicare rules. The requested test is not approved by the Food and Drug 
Administration (FDA). Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve Tempus xF 
testing.
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 mentally intact, highly motivated and 
now is the right time for IRF admission. You also say that the enrollee completed surgery and treatments and 
this is the last piece needed to gain independence and move forward for the kidney transplant. The Plan denied 
your request. The Plan says criteria for admission to the acute inpatient rehabilitation setting have not been met.  
 
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 the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The enrollees care needs can be met at a lower 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: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on August 27, 2023, to 
August 30, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says that it is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission it was 
reasonable for the admitting physician to expect that the enrollees necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights with supporting documentation of 
the enrollees history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse 
event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on August 27, 2023, to August 30, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 5, 2023, to May 
9, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described as sepsis, 
unspecified organism, and secondary diagnosis code R65.20, described as severe sepsis without septic shock. 
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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that documentation does not support the billed codes. Our physician 
reviewer found that the enrollee is a 60-year-old male who was treated in the hospital with cellulitis of the leg. 
Workup revealed no hypotension, no hypoxia, baseline mental status, normal platelet count, normal bilirubin, 
no report of oliguria, and creatinine 3.26. However, the enrollee has end stage renal disease, and the elevated 
creatinine was expected. There was insufficient support for sepsis being a diagnosis. The Sepsis 3 criteria was 
not met as there was insufficient support that there was organ failure directly related to the infection. Therefore, 
the diagnosis codes are not supported for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 5, 2023, to May 9, 2023, at the Diagnosis Related Group 
(DRG) originally billed.