Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryoneurolysis (Iovera) (64640). 
 
You asked the Plan to pre-approve Iovera. You say that the enrollee has tried and failed conservative 
treatments with little success. You also say that the enrollee reports that their ability to complete activities of 
daily living (ADLs) and quality of life are suffering as a result of their pain. The Plan denied your request. The 
Plan says this is 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 Iovera. Our reviewer says that the 
requested Iovera procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of 
the Iovera treatment for post-op pain management following total knee arthroplasty as safe and effective. Additionally, there is no indication that standard post-op pain management would be insufficient for this 
enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested cryoneurolysis (Iovera) 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 Iovera have not been met. Therefore, we decided that the Plan does not have to 
pre-approve cryoneurolysis (Iovera) (64640).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 Botox is covered for specific indications only. 
 
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 gastroparesis. This 
diagnosis is not a condition for which Botox is covered by the Medicare criteria. The services are therefore not 
reasonable or medically necessary based on the submitted records. 
 
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 Botox.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 16, 2023, billed with 
multiple codes including 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel 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 16, 2023, billed with multiple codes including 81351.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the enrollee's 
rehabilitation and medical needs can be met at a lower level of care with skilled intermittent therapy and 
nursing in a community setting.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. 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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found that the enrollee has age related osteoporosis without 
osteoporotic fracture and the 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 are not satisfied, and 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet 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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has diagnoses of stage 3 chronic kidney disease and iron deficiency anemia. The 
documentation does not support that the enrollee has tried and failed Infed (iron dextran) and Venofer (iron 
sucrose). The documentation does not support that Infed (iron dextran) and Venofer (iron sucrose) would likely 
be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313) and
electronic connection (E2311) for the enrollee.

You asked the Plan to pre-approve an expandable controller, harness and electronic connection. You say that
these items are medically necessary. The Plan denied your request. The Plan says that although there are three
approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to
control these power options through the joystick.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, harness and electronic connection. Our Medical Director states that the documentation does not
support that an expandable controller, harness, and electronic connection are medically necessary for this
enrollee to control the two power options through a joystick. Our Medical Director found that the enrollee's
condition does not meet criteria for coverage of an expandable controller, harness and electronic connection.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller, harness and electronic connection have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness
(E2313) and electronic connection (E2311) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve the K3 microprocessor foot. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the request for 
microprocessor foot exceeds the enrollee's need and does not meet the Medicare criteria of reasonable and 
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 the K3 microprocessor foot. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested endoskeletal ankle foot system, microprocessor controlled 
feature, dorsiflexion and/or plantar flexion control, includes power source L5973 exceeds the enrollee's medical 
needs per Local Coverage Determination (LCD) Lower Limb Prostheses L33787 and per Social Security Act, 
Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are 
not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of 
a malformed body member. The physician documentation does not reveal extenuating factors that require a 
microprocessor ankle foot system over a mechanical ankle foot.  
 
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 K3 microprocessor foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the endoskeletal ankle foot system, microprocessor-controlled feature, 
dorsiflexion and/or plantar flexion control, includes power source (L5973).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is stable on this mediation. 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 methotrexate.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the daratumumab injection, 10 mg and hyaluronidase-
fihj (J9144). 
 
You asked the Plan to pre-approve the medication. You say that please see the attached letter of medical 
necessity and clinical documentation in support of the appeal request. The Plan denied your request. The Plan 
says the records do not support that this care is needed to treat the enrollee's condition and does not support the 
coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 medication. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested use of Darzalex Faspro (daratumumab and hyaluronidase-fihj) is not Food and Drug Administration-approved for the enrollee's diagnosis of acquired hemolytic anemia, unspecified (D59.9). 
The use of Darzalex Faspro (daratumumab and hyaluronidase-fihj) for treatment of acquired hemolytic anemia, 
unspecified (D59.9) is not supported by one of the major drug compendia. The CMS-approved medical journal 
list is relevant for drugs used in cancer treatment. The provided records in this case do not document any 
cancer treatment. The use of Darzalex Faspro (daratumumab and hyaluronidase-fihj) for treatment of acquired 
hemolytic anemia, unspecified (D59.9) is not listed as not indicated, not supported or not recommended in any 
of the compendia. The use of Darzalex Faspro (daratumumab and hyaluronidase-fihj) for treatment of acquired 
hemolytic anemia, unspecified (D59.9) does not meet Medicare criteria for safe and effective and otherwise 
reasonable and necessary for this 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 the daratumumab injection, 10 mg and hyaluronidase-fihj (J9144).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of Minuteman fusion device. 
 
You asked the Plan to pre-approve the Minuteman device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is 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 Minuteman device. Our reviewer 
says that the requested Minuteman device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do not 
fully support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack 
of large-volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition as discussed above. According to the Food and Drug Administration (FDA), the HA Minuteman G3-R MIS Fusion Plate is a posterior, non-pedicle supplemental fixation device, intended for use at 
a single level in the non-cervical spine (T1-S1). Therefore, the reviewer found that the requested Minuteman 
device 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of Minuteman fusion device.
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 will not get the rehabilitation you need without 
an IRF admission. The Plan denied your request. The Plan says the request is not medically 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 the enrollee needs to work towards getting strength 
enough to learn to use and function with the new prosthetics from having the leg amputated. The Plan denied 
your request. The Plan says the enrollee's condition does not meet all of the requirements for inpatient 
rehabilitation admission. The Plan says services may be provided at a lower level of care.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Puraply skin substitute and application (Q4197, 15271, 
15272). 
 
You asked the Plan to pre-approve Puraply skin substitute and application. You say that this is medically 
necessary. The Plan denied your request. The Plan says the records do not show that the enrollee has failed to 
respond to standard wound care. 
 
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 Puraply skin substitute and application. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the records do not clarify the enrollee's underlying medical conditions 
including glucose control have been optimized to aid in wound healing as is the standard 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 Puraply skin substitute and application have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Puraply skin substitute and application (Q4197, 15271, 
15272).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex walk system (L5981). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested prosthetic parts do not meet the Medicare criteria for being reasonable and 
necessary. 
 The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation does not reveal a  change in the physiological condition of the patient, 
irreparable wear of the device or a part of the device; or that the  condition of the device, or part of the device, 
requires repairs and the cost of such repairs would be more than 60% of the cost of a replacement device, or of 
the part being replaced. The documentation does not reveal sufficient clinical documentation of functional need 
for the technologic or design feature of a given type of foot.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a flex walk system (L5981).