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

 
We decided that the Plan does not have to pre-approve Udenyca (pegfilgrastim-cbqv) injections.  
 
You asked the Plan to pre-approve the treatment with Udenyca. You say that this is necessary to prevent febrile 
neutropenia.  The Plan denied your request. The Plan says the planned drug regimen does not have a high 
likelihood of causing febrile neutropenia.  
 
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 treatment with Udenyca. Our 
reviewer says that the requested drug is not medically reasonable and necessary.  Our physician reviewer found 
based on the medical records provided and the Medicare-approved major drug compendia, there is no 
documentation that the Udenyca (pegfilgrastim-cbqv) at issue in this case meets all Medicare criteria for safe 
and effective for the enrollee. Provided medical records and the Medicare-approved major drug compendia do 
not support that the carboplatin/Alimta will place the enrollee at significant risk for febrile neutropenia as 
required for use of this agent.  
 
 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 treatment with Udenyca have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Udenyca (pegfilgrastim-cbqv) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural neurolysis procedure (62264). 
 
You asked the Plan to pre-approve the epidural neurolysis procedure. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is experimental and non-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 epidural neurolysis procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient medical literature to support the overall use of this 
procedure. More research is needed to show safety and efficacy of the procedure.  
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 epidural neurolysis procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an epidural neurolysis procedure (62264).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric services provided on January 27, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the OON psychiatric services. You say that you have been going to this OON 
provider for about 20-25 years and they were at one time in-network. You say that you were told he was now 
OON but that you could still see him.  The Plan denied your request. The Plan says the services in dispute were 
provided OON without prior authorization.  
 
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 at issue in this case is not a network provider with the Plan. 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 OON psychiatric services. Our reviewer says that the criteria for coverage of 
OON care have not been met.  Our physician reviewer found the documentation does not indicate that 
continued evaluation and management of an out-of-network psychiatric provider was medically necessary.  
There is no documentation that would indicate that the beneficiary required ongoing, active treatment. The 
enrollee's medical management could have safely been transitioned to an in-network specialist.  
 
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 OON psychiatric services have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the OON psychiatric services. Therefore, we decided that 
the Plan does not have to pay for psychiatric services provided on January 27, 2023, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim NEO system.  
 
You asked the Plan to pre-approve a Barostim NEO system. You say that  this procedure is medically 
necessary and has been approved for other patients by multiple insurances. The Plan denied your request. The 
Plan says placement of the Barostim Neo system is not medically necessary for this enrollee.  
 
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 Barostim NEO system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this 
time the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical management. 
 
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 Barostim NEO system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim NEO system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve somatuline. 
 
You asked the Plan to pre-approve somatuline. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says the enrollee is enrolled in a clinical trial, so the Plan is not responsible for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve somatuline as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve somatuline.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 23, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
eligible to bill Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided on January 23, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion pump supplies (A4305 and A4223) provided from 
October 26, 2022, to November 24, 2022. 
 
You asked the Plan to pay for infusion pump supplies. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says these supplies are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems and related 
drugs and supplies are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infusion pump supplies have not been met. Therefore, we decided that the Plan does not have to 
pay for infusion pump supplies (A4305 and A4223) provided from October 26, 2022, to November 24, 2022.
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 services are medically necessary. The Plan 
denied your request. The Plan says your needs may be met with less frequent therapy services in a long-term 
care facility.  
 
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 you do not require treatment by multiple therapies. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (C2624, 33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (C2624, 33289).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. 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 the enrollees 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care at an inpatient mental health facility.  
 
You asked the Plan to pre-approve the continued care. You say that the enrollee reports that the current 
medication regime is not effective for the enrollee to function at a baseline level on an outpatient basis without 
concerns of danger to self. You also say that the enrollee requires continued care. The Plan denied your request. 
The Plan says the documentation shows that the enrollee is improving. The Plan also says outpatient care may 
be helpful.  
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 to pre-approve the continued care. Our reviewer says 
that the request for continued care is not medically necessary. Our physician reviewer found the documentation 
indicate the enrollee did not appear to require inpatient mental health treatment beyond the date in question as 
she was not a danger to herself or others and does not have auditory or visual hallucinations. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services were 
reasonably expected to improve the enrollees condition or for the purpose of diagnosis beyond the date in 
question. Therefore, the reviewer found that the request for continued care 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 continued care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued care at an inpatient mental health facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power wheelchair (K0813), and unspecified 
power mobility device (K0899). 
 
You asked the Plan to pre-approve the power mobility devices. You say that the enrollee just recently released 
from sub-acute rehab after multiple hospitalizations this year and experiencing significant weakness and 
neuropathy and chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says 
the requested Group 1 power wheelchair is not medically necessary. The Plan also says that a K0899 power 
mobility device is not considered reasonable and necessary based on Medicare guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power mobility devices. Our 
reviewer says that the requested Group 1 power wheelchair is not medically necessary. Our physician reviewer 
found the documentation available for review does not support that the enrollee requires a power mobility 
device to accomplish mobility related self-care tasks in the home. There is no indication they are unable to use 
an alternative assistive device. Therefore, the reviewer found that the requested Group 1 power wheelchair 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 power mobility devices have not been met. The file does not support that the 
enrollee requires a power mobility device to accomplish mobility related self-care tasks in the home. 
Additionally, power mobility devices coded as K0899 are not medically reasonable or necessary. Therefore, we 
decided that the Plan does not have to pre-approve a Group 1 power wheelchair (K0813), and unspecified 
power mobility device (K0899).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says  the IRF services requested do not meet the 
requirements for approval.  
 
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 enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care provided on January 06, 2023. 
 
You asked the Plan to pay for subsequent observation care. You say that this service is supported in the 
records. 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 subsequent 
observation care provided on January 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
February 17, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the services were 
medically necessary. 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 a home visit for the 
evaluation and management provided on February 17, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the Plan requires a trial of Venofer before it will approve Feraheme. 
 
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 Feraheme. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Feraheme. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Venofer. The record does not show that this drug 
would likely be less effective and/or 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Feraheme.