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

 
We decided that the Plan does not have to pre-approve Ilumya. 
 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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has plaque psoriasis. She 
has not tried and failed the Plan's required drugs, Remicade, Inflectra, or infliximab and Stelara. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, Ilumya 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cooled radiofrequency ablation of the right medial 
branches of C3 and C4 (64999).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
service.  
 
 
  
 
 
 
 
The Plan follows Medicare rules. Medicare rules say that Non-thermal modalities for facet joint denervation 
including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation 
are 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that cooled radiofrequency ablation 
(RFA) is specifically not covered by the Centers for Medicare and Medicaid Services (CMS). Only 
conventional RFA is covered. Therefore, this 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cooled radiofrequency ablation of the right medial branches of C3 and C4 (64999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring device (K1024, K1032). 
 
You asked the Plan to pre-approve the Koya Dayspring device. You say that you are appealing the denial and 
request reconsideration of the Koya Dayspring non-pneumatic compression device. The Plan denied your 
request. The Plan says this device is considered experimental and investigational as medical studies haven't 
proven this service/item is helpful for the treatment of the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The clinical value and effectiveness of Koya Dayspring (non-
pneumatic) Active Compression Garment System in the in the setting of lymphedema have not been 
demonstrated in the peer-reviewed literature. Based on this information, we decided that Medicare rules for 
coverage of the Koya Dayspring device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Koya Dayspring device (K1024, K1032).
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 are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the coverage criteria has 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 complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. 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 inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation does not 
support that she would meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services 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: 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 with their many comorbidities, the patient's clinical 
condition meets full acute inpatient rehabilitation criteria. The Plan denied your request. The Plan says based 
on the available information, an IRF admission is not reasonable and 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 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.  Our reviewer also found that 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: 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 IRF care is necessary to regain functional mobility 
and strength. The Plan denied your request. The Plan says IRF care is not reasonable and 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 enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee's does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. 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 inpatient rehabilitation facility. The medical records do not support that the enrollee would meet 
criteria for admission to an acute inpatient rehabilitation facility. The enrollee can receive further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair, adult size, patient weight capacity up 
to and including 300 pounds (E1038). 
 
You asked the Plan to pre-approve a transport chair. You say that the transport chair is needed to get to 
appointments and it needs to be light weight for the caregiver to lift it. The Plan denied your request. The Plan 
says the requested use of the transport chair is for outside of the home therefore, the Medicare medically 
necessity criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a transport chair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a transport chair, adult size, patient weight capacity up to and including 300 pounds (E1038).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carbidopa-Levodopa. 
 
You asked the Plan to pre-approve the medication. 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 Carbidopa-Levodopa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10060 billed for date of service March 17, 
2023.  
 
You asked the Plan to pay for procedure code 10060. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 10060 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 10060 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 10060 billed for date of service March 17, 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 are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has 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 complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation does not support that he would meet criteria for admission to an acute inpatient rehabilitation 
facility. The enrollee can receive further services 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: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 01210 and 64999. We 
decided that the Plan does not have to pay for the services described by procedure code 76942.  
 
You asked the Plan to pay for procedure codes 76942, 01210, and 64999 performed on date of service March 
20, 2023. You say that codes 76942, 01210, and 64999 should be paid as billed because they are supported in 
the medical records. The Plan says that 76942 is denied because it was billed without the required modifier -26. 
01210 and 64999 were handled as an original decision reopen for New and Material Evidence, therefore no 
appeal decision was made. 
 
We decided that the Plan has to pay for the services described by procedure codes 01210 and 64999.  
 
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 make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 01210 and 64999.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 76942. 
 
The Plan follows Medicare rules. Medicare rules say that carriers may not pay for the technical component 
(TC) of radiology services furnished to hospital patients. 
 
We looked at the file and Medicare rules. We confirmed that 76942 is a radiology service which has a separate 
TC and PC, and the enrollee received this service at an inpatient hospital. We confirmed that in this case, 
76942 was not billed with modifier -26. According to Medicare rules, modifier -26 is required as the TC of a 
radiology service which has both a TC and PC cannot be paid to the physician when the enrollee receives 
services while at a hospital. Based on this information, we decided that Medicare rules for coverage of the 
services described by procedure code(s) 76942 have not been met. Therefore, we decided that the Plan does not 
have to pay for the services described by procedure code 76942. 
 
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 compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that it is your recommendation that the 
patient receive compression stockings to help with their edema. You also say that this is crucial to the patient's 
health to help with leg swelling as this could potentially cause multiple other health related concerns. The Plan 
denied your request. The Plan says per Medicare guidelines the requested item is not approved. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (PCD) and appliance 
to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the PCD and appliance. The Plan denied your request. The Plan says this is 
available from an in-network provider. 
 
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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve the pneumatic 
compression device (PCD) and appliance to be provided by an out-of-network (OON) provider.
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 patient still needs help because they 
are not making any progress. You also say that the patient cannot be sent to a nursing home for care. The Plan 
denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 patient is currently undergoing treatment at an acute care hospital (ACH) for 
COVID-19. The patient is not intubated/ventilated. There is no evidence that the patient requires services that 
are not currently available. Our reviewer found that as LTACHs and ACHs are licensed to provide the same 
level of care, there is no advantage in transferring the patient to the LTACH. The patient can remain at the 
current ACH until such time no acute services are required. Our physician reviewer also found that the patient 
can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 14, 2022, billed with 
codes 87899, 87500, 87481, 87900, 87640, 87652, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that the codes are payable. The Plan denied 
your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single code as required. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the genetic testing provided on June 14, 2022, billed with codes 87899, 87500, 87481, 87900, 
87640, 87652, 87653, and 87798.