Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from May 10, 2023, to May 14, 
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 that payment of DRG 871 remains not supported. 
 
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. We find that The plan has not provided any medical records from this inpatient 
admission. The plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for 
inpatient hospital services rendered from May 10, 2023, to May 14, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve darbepoetin alfa injection, 2610 micrograms (mcg) 
(non-ESRD use) (J0881). 
 
You asked the Plan to pre-approve the medication. You say that please reconsider authorization approval. The 
Plan denied your request. The Plan says based on the enrollees weight (49.71 kilograms) and indication 
(D63.1- Anemia in chronic kidney disease), only 390 mcg is appropriate. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the medication. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has a diagnosis of anemia secondary to chronic 
kidney disease not on dialysis. The Food and Drug Administration has stated that the requested drug is 
indicated for the enrollee's condition. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules of the requested dose. 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve darbepoetin alfa injection, 2610 micrograms (mcg) (non-ESRD use) (J0881).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Infuse BMP allograft during an approved 
spinal fusion procedure.  
 
You asked the Plan to pre-approve the Infuse BMP allograft. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of this allograft in the setting 
posterior lumbar spine fusion surgery 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 pre-approve the Infuse BMP allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Infuse BMP allograft is not medically reasonable or 
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 Infuse BMP allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the use of Infuse BMP allograft during an approved spinal fusion procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remaining limited oral evaluation (D0140) billed on July 
20, 2023. 
 
You asked the Plan to pay for the remaining limited oral evaluation. You say that this was urgent, and you 
needed to be seen. The Plan denied your request. The Plan says this service is a duplicate of a previously paid 
service and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 20, 2023. Comparison of the two claim lines shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the additional limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the remaining limited oral 
evaluation (D0140) provided on July 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health skilled nursing and 2 physical therapy 
visits.  

You asked the Plan to pre-approve 9 home health skilled nursing and 2 physical therapy visits. You say that 
you would like to request reconsideration of the denied home health services and that the services requested 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 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 clinical 
documentation does not specify any acute clinical concerns, medication or plan of care changes, complex 
wound care thus the records do not show that additional home health skilled nursing visits are required to 
effectively provide treatment, care, and/or services in order to improve the enrollee's 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 9 home health skilled nursing and 2 physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 5, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trodelvy. 
 
You asked the Plan to pre-approve the drug. You say that the medications requested include molecularly 
directed therapy supported by clinical and pre-clinical evidence and could potentially prolong the enrollee's 
survival, while optimizing their quality of life. The Plan denied your request. The Plan says Trodelvy is 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 the drugs. Our reviewer says that 
Trodelvy is not medically necessary. Our physician reviewer found that the requested use of Trodelvy is not 
FDA-approved. Trodelvy is also not supported by one of the major drug compendia or by clinical research. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Trodelvy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional medial branch block. 
 
You asked the Plan to pre-approve the additional medial branch block. You say that this would help with the 
enrollee's chronic pain. The Plan denied your request. The Plan says this does not meet the LCD criteria for 
coverage. 
 
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 additional medial branch block. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the LCD limits the 
number of medial branches blocks to 2 levels bilaterally. Since this request exceeds that number; only 2 levels 
are deemed 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 additional medial branch block have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the additional medial branch block.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 1, 2023, billed with 
codes 81225, 81226, 81240, and 81241. 
 
You asked the Plan to pay for the genetic testing billed. You say that the documentation supports the services 
billed. 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 combined cardio and pharmacogenetics 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 May 1, 2023, billed with codes 81225, 
81226, 81240, and 81241.
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 is the physician's 
recommendation and plan of treatment after evaluation of the enrollee. The Plan denied your request. The Plan 
says the request is not medically necessary. 
 
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 had a recent intracranial bleed and was in an acute rehabilitation 
facility but was readmitted after a mental status change. The enrollee was treated for sepsis from a urinary tract 
infection and infected sacral ulcer, which required debridement and wound vac placement. The enrollee had a 
percutaneous endoscopic gastrostomy (PEG) tube placed. The enrollee does not have care requirements (e.g., 
ventilator weaning or complex wound care) that meet LTACH admission requirements. 
 
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 an upgraded continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that a new CGM is necessary because it will be easier to 
monitor your blood sugar and the previous CGM is inconstant. The Plan denied your request. The Plan says the 
denial of authorization for the CGM is correct, because the clinical records did not indicate that the member's 
current CGM was defective or broken. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment. 
 
  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 CGM. Our reviewer says that the 
coverage criteria was not met. Our physician reviewer found that the Libre 2 should provide blood glucose data 
and high and low alerts; although scanning is required to see the blood glucose level, a low or high alert should 
activate even if the enrollee is not scanning so unless the Libre 2 is broken, it seems outside of the provided 
medical necessity criteria for a switch to Libre3 to be justified. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an upgraded continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve the PAE. You say that this is a covered procedure under Medicare. The Plan 
denied your request. The Plan says this is considered experimental and therefore is not covered. 
 
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 PAE. Our reviewer says that the 
requested PAE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
there are very limited studies that have demonstrated possible short-term safety and efficacy. The most recent 
American Urological Association (AUA) guidelines do not recommend this procedure outside of a clinical trial 
setting due to the heterogeneity in the available literature and safety concerns regarding radiation exposure, 
postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate compared with more traditional methods (eg, transurethral resection of the prostate [TURP]). Therefore, the reviewer found 
that the requested PAE is not medically reasonable or 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 PAE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve prostate artery embolization (PAE).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDx test (0037U) provided on July 20, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that the treating physician determined that 
ordering the FoundationOne CDx test was medically necessary for the enrollee to assist in treatment decisions. 
The Plan denied your request. The Plan says that the rendered services require prior authorization when 
rendered by 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 you never need approval in advance for out-of-network services from out-of-network providers. 
 
We looked at the file and Medicare rules. The health Plan contract specifically says you never need approval in 
advance for out-of-network services from out-of-network providers. Since the provider is an out of network 
then the prior authorization does not apply in this case. Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have been met. Therefore, we decided that the Plan has to pay for 
FoundationOne CDx test (0037U) provided on July 20, 2023, by an out-of-network (OON) provider.   
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0482) provided on date of service June 5, 2023. 
 
You asked the Plan to pay for drug testing. You say that you have reported and documented the services at 
issue correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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 rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the 
intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial cites the absence of a physician or practitioner order for the 
services at issue. We found in the case record that an order signed by the practitioner has been provided. It is 
the Plan's responsibility to support its denial with evidence. In this case, the Plan's denial is not supported, so 
we must find in your favor. Therefore, we decided that the Plan has to pay for drug testing (G0482) provided 
on date of service June 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pay for the CPAP device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the enrollee's current device is less than 5 years old. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pay for 
the continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on March 29, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81455) provided on March 29, 2023.