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

 
We decided that the Plan does not have to pre-approve Denosumab (Prolia) injection (J0897). 
 You asked the Plan to pre-approve the medication. You say that this medication is medically necessary for the 
enrollee to take. The Plan denied your request. The Plan says the enrollee does not meet the step therapy 
criteria. 
 
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 medication. Our reviewer says that 
the enrollee has not met the Plan's criteria for coverage. Our physician reviewer found the Plan requires a trial 
of drug of one oral bisphosphonate and one intravenous bisphosphonate before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided 
indicating that the plan's required drug(s) 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Denosumab (Prolia) injection (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve Vertiflex. You say that an epidural did not help, and you need this 
procedure due to extreme lower back pain. The Plan denied your request. The Plan says that you do not meet 
the requirements for approval. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex is considered experimental. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of home health care services. 
 
You asked the Plan to pre-approve home health services. You say that the requested continuation of home 
health care services is medically necessary.  The Plan denied your request. The Plan says the enrollee does not 
meet criteria for continued home health care services. 
 
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 enrollee does not meet criteria for continued home health care services. Our physician reviewer 
found based on the documentation provided, the enrollee does not have documented skilled nursing needs (i.e., 
IVs, complex wound care, new ostomy).  As such, HH 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 the continuation of home health care services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 8, 2022, to 
October 12, 2022, 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 A41.9 
and R65.20 are supported in the documentation, therefore, the claim should be paid at the DRG originally 
billed. The Plan denied your request. The Plan says A41.9 and R65.20 are not supported in the documentation. 
 
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 A41.9, defined as sepsis, 
unspecified organism, and secondary diagnosis R65.20, defined 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 principal diagnosis A41.9 and secondary diagnosis R65.20 are not 
supported in the documentation. Our physician reviewer found the enrollee is a 71-year-old who was admitted 
and treated for weakness, nausea, vomiting, and cough for 3 days. They were noted to have a fever and 
leukocytosis. A chest x-ray showed infiltrates suggesting pneumonia, which was treated with antibiotics and 
fluids. Workup also revealed the enrollee was tolerating room air without hypoxia. There was no 
documentation of hypotension. The enrollee had normal creatinine, normal bilirubin, normal platelet count, no 
oliguria, and they were alert and oriented. The enrollee's Sequential Organ Failure Assessment (SOFA) score 
was 0 and they did not meet Sepsis 3 criteria. There was no evidence of organ failure directly being related to a 
dysregulated response to systemic infection.  
 
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 October 8, 2022, to October 12, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc.  
You asked the Plan to pre-approve Synvisc. You say that Synvisc is medically necessary. The Plan denied your 
request. The Plan says a trial of Orthovisc or Supartz is required before alternatives can be considered. 
 
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 Synvisc. Our reviewer says that 
Synvisc is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, multiple braking system, variable wheel 
resistance walker (E0147). 
 
You asked the Plan to pre-approve a heavy duty, multiple braking system, variable wheel resistance walker 
(E0147). You say that the heavy duty, multiple braking system, variable wheel resistance walker (E01047) is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a 
heavy duty, multiple braking system, variable wheel resistance walker (E01047).  
 
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 a heavy duty, multiple braking system, 
variable wheel resistance walker (E0147). Our reviewer says that the enrollee does not meet criteria for a heavy 
duty, multiple braking system, variable wheel resistance walker (E01047).  Our physician reviewer found the heavy duty, multiple braking system, variable wheel resistance walker (E0147) criteria have not been met per 
LCD L33791. The documentation does not reveal that the enollee cannot use a standard walker due to a severe 
neurologic disorder or other condition causing the restricted use of one hand. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a heavy duty, multiple braking system, variable wheel resistance walker 
(E0147). have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, 
multiple braking system, variable wheel resistance walker (E0147).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this modality of pain management is still being studied to see if this treatment is as 
good or better than standard treatment for chronic back pain. 
 
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 stimulator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is an experimental/investigational procedure which 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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SPRINT peripheral nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 system. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic 
obstructive pulmonary disease (COPD) with chronic hypoxic and hypercarbic respiratory failure. The Life2000 
system is not a true ventilator because it is not capable of providing full ventilatory support. It is intended to be 
used during activity, and there is inadequate evidence that it is beneficial in the treatment of any chronic lung 
disease. The services are therefore 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 a Life2000 system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 7, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 83520 is "Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified". 
 
We find that CPT code 83520 is not supported in the medical record. Specifically, the order/lab requisition did 
not include what laboratory test was ordered/requested in order to validate the billed code. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (81436) provided on June 19, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that you agree with this testing because you were 
diagnosed with endometrial cancer in 2005. The Plan denied your request. The Plan says non-emergent 
services with in-network providers require prior authorization before services being rendered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is in-network provider with the Plan. The health Plan contract specifically 
says on page 47 that some of the services listed in the Medical Benefits Chart are covered as in-network services only if your doctor or other network provider gets approval in advance. The Plan did not pre-approve 
the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the genetic testing (81436) provided on June 19, 
2023, 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 enrollee would benefit from this care. 
The Plan denied your request. The Plan says the enrollee's needs can be safely managed at the current facility 
until they are more stable for transfer to another level of care. 
 
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 is receiving appropriate care in their current acute care setting. The 
documentation does not support that LTACH services are medically appropriate 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 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 EsoGuard test provided on April 26, 2023. 
 
You asked the Plan to pay for the EsoGuard test. You say that the EsoGuard test was medically necessary. The 
Plan denied your request. The Plan says the EsoGuard test is not medically necessary. 
 
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 EsoGuard test. Our reviewer says that 
the requested EsoGuard test is not considered medically reasonable and necessary. Our physician reviewer 
found that the available literature refutes the manufacturer's claim of standard-of-care. In lieu of endoscopic evaluation, EsoCheck (non-endoscopic tissue collection) is a promising investigational option. The medical 
necessity and appropriateness of the EsoGuard assay is not demonstrated in this case based on available records 
that support low likelihood of nondysplastic Barrett's, and uncertainty that the enrollee has gastroesophageal 
reflux disease (GERD). 
 
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 EsoGuard test have not been met. Therefore, we decided that the Plan does 
not have to pay for the EsoGuard test provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral surgery services. 
 
You asked the Plan to pre-approve oral surgery services. You say that you were denied medical services 
coverage for oral surgery, which involves the complete extraction of all of your teeth. You also say that two 
different dentists have informed you that this acidic dental erosion from your gastric bypass surgery is the 
reason why your teeth are decaying and breaking off. The Plan denied your request. The Plan says your 
provider did not submit the clinical information needed to approve the requested service.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers oral surgery 
services when the services are medically necessary and reasonable.  
 
  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 oral surgery services. Our reviewer says 
that based on the limited information includes, the requested procedures for extractions, general anesthesia, 
implants, and alveoloplasty are not medically necessary. Our physician reviewer found although there was a 
clinical note by the provider stating that you have a lot of decay, there were no x-rays included in the appeal, or 
photos to assess the condition of your teeth and request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of oral surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve oral surgery services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is at a high risk of injury if 
they do not receive the LTACH services. The Plan denied your request. The Plan says the enrollee's condition 
does not meet the requirements for LTACH services. 
 
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's wound care needs are currently being met at the facility provided by the 
health Plan. 
 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99397 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code 99397. The Plan denied your request. The Plan says the billed 
code is not covered for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99397 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code 99397 is not covered. Based on this information, we decided that Medicare rules for coverage of procedure code 99397 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99397 billed for date of service May 2, 2023.