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

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 You asked the Plan to pre-approve Ocrevus. You say that the enrollee has tried and failed therapies that include 
Copaxone and Glatiramer. The Plan denied your request. The Plan says that the step therapy requirements have 
not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ocrevus. Our reviewer says that 
Ocrevus is not medically necessary. Our physician reviewer found that the enrollee has relapsing remitting 
multiple sclerosis and the requested medication is a new start. However, there is no indication that the enrollee 
has tried and failed the Plan's preferred step one alternative. Also, there is no indication that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. Therefore, 
the elements of the coverage criteria have not been 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 Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided March 7, 2023, to March 
10, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 7, 2023. An NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services provided March 7, 2023, 
to March 10, 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 this care is medically necessary. The Plan denied 
your request. The Plan says the necessary services can be provided safely in other settings 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on March 09, 2023. 
 
You asked the Plan to pay for the mental health services. You say that you are requesting reconsideration for 
the denied payment. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the mental health 
services provided on March 09, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Quviviq tablet. 
 
You asked the Plan to pre-approve Quviviq. You say that the requested drug is a medical necessity for the 
enrollee. 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Quviviq 
tablet.  
 
Benefits for Quviviq may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar 
approach) for decompression (0275T). 
 
You asked the Plan to pre-approve percutaneous laminotomy surgery. 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 effective for services performed on or after January 9, 
2014, PILD will be covered by Medicare through CED for beneficiaries with LSS who are enrolled in an 
approved clinical study that meets the following criteria.  
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 percutaneous laminotomy surgery. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found percutaneous 
laminotomy surgery is experimental. More research is 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 percutaneous laminotomy surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) for 
decompression (0275T).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 10, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this was the only safe way to transfer the 
enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the ambulance services 
provided on February 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment inpatient psychiatric 
treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of June 5, 2023, forward and could have been treated in a 
lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions. He was not showing any behaviors or aggression. He was being cooperative and 
compliant while not showing any acute threats to safety as he awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve electronic connection to power options (E2311) expandable 
controller (E2377) expandable controller harness (E2313).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are appealing the denial of the 
electronic controls required for this enrollee's power wheelchair.  The Plan denied your request. The Plan says 
that the upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is non-ambulatory and requires a power wheelchair for mobility and 
performing basic daily activities. The enrollee cannot perform pressure relief independently due to upper 
extremity weakness and requires a power wheelchair with power tilt and recline for adequate pressure relief 
and positioning. The enrollee requires power elevating leg rests for positioning of lower extremities and lower 
extremity spasticity. The complexity of the seating and positioning needs necessitates a more complex group 3 
power wheelchair base. The expandable controller with harness and electronic connection are necessary to 
operate the group 3 power wheelchair base and the three power options via a joystick. Therefore, the 
expandable controller (E2377) with harness (E2313) and electronic connection (E2311) is 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 the upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve electronic connection to power options (E2311) expandable controller (E2377) expandable 
controller harness (E2313).   
 
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 a 90 degree-front frame bend, a 7" v-front frame bend, 
an adjustable height rigidizer bar, a v-front-footrest taper and a composite side guards-direct mount receiver 
(K0108x7). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says Medicare Guidance says the items must 
be durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a 90 degree-front frame bend, a 7" v-front frame bend, an 
adjustable height rigidizer bar, a v-front-footrest taper and a composite side guards-direct mount receiver 
(K0108x7).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87900. We decided that the Plan does not have to pay 
for procedure code 87652.  

You asked the Plan to pay for procedure codes 87652 and 87900 billed for date of service January 31, 2023. 
You say that these are covered codes which were used appropriately. The Plan says that these services are not 
supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We decided that the Plan has to pay for procedure code 87900.  
 
In this case, the CPT Code Manual definition of code 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. 
 
We asked our coder 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 procedure code 87900. Our reviewer says that this code was 
used appropriately. Our reviewer found that the exam did include the enrollee's susceptibility or resistance to 
drugs aimed at a virus; therefore, documentation supports code 87900. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87900 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87900.  
 
We also decided that the Plan does not have to pay for procedure code 87652. 
 
In this case, the CPT Code Manual definition of code 87652 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, quantification. 
 
We asked our coder 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 procedure code 87652. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found that the medical record does not include evidence that 
Strep Group A was tested or verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87652 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87652. 
 
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 Zometa for the enrollee.
You asked the Plan to pre-approve Zometa. You say that this is medically necessary. The Plan denied your request. The Plan says that Zometa is not supported for this indication and Reclast should be the format used instead.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Zometa. Our Medical Director states that the Zometa is not FDA-approved for the enrollee's diagnosis and would not be considered to be safe and effective and otherwise reasonable and necessary for this enrollee. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Zometa.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zometa have not been met. Therefore, we decided that the Plan does not have to pre-approve Zometa for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 8 home health physical therapy visits 
(G0151). 
 
You asked the Plan to pre-approve home health services. You say that this is 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 enrollee 
does not require additional skilled rehabilitation services to effectively provide treatment, care, and/or services 
in order to improve the enrollees condition, perform a maintenance program to maintain the enrollees 
condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. 
 
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 an additional 8 home health physical therapy visits (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for guided tissue regeneration services (D7956) provided 
on January 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 19, 2023. 
Therefore, we decided that the Plan does not have to pay more for guided tissue regeneration services (D7956) 
provided on January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedure (D9215) provided on March 7, 2023.  
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial. The Plan denied 
your request. The Plan says this service is not covered under your Plan. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Local anesthesia in 
conjunction with operative or surgical procedure (D9215) is not covered under the Plan's dental benefits 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9215 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for local anesthesia 
in conjunction with operative or surgical procedure (D9215) provided on March 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for left 
total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The 
Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 
2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found there is no documentation provided to support the expectation the enrollee 
will require a greater than 2 midnight stay. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.