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

 
We decided that the Plan does not have to pay for laboratory tests (87150, 87500, and 87801) provided on 
November 16, 2022. 
 
You asked the Plan to pay for 87150, 87500, 87801. You say that specimens must be processed without delay. 
The Plan denied your request. The Plan says there is a more appropriate panel code that should be used: 87507. 
 
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 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. The CPT Code 
Manual definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); vancomycin 
resistance (eg, enterococcus species van A, van B), amplified probe technique. The CPT Code Manual 
definition of code 87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique. 
 
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 87150, 87500, and 87801. Our reviewer says that these codes 
do not meet criteria for payment. Our reviewer found guidelines say that if a panel of tests is performed, the 
panel should be reported instead of individual procedure codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87150, 87500, and 87801 have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory tests (87150, 87500, and 87801) provided on November 16, 2022.
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 LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for a LTACH admission. 
 
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 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 acute hospital can provide for all the enrollees present inpatient care needs and 
the enrollee is receiving an appropriate level of care in the present setting. The provided records do not explain 
what care services will be provided in the LTACH that are not currently available. The records do not support 
the need to transfer from one acute hospital to another. Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility, or a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avsola (Q5121). 
 
You asked the Plan to pre-approve Avsola. You say that the enrollee is unable to take Methotrexate or 
Leflunomide. You say that Plaqenil is not indicated for the enrollee's diagnosis and would take too long to start 
working. You say that the enrollee has been on the Avsola infusions since July 2023 and has tolerated and did 
show improvement. The Plan denied your request. The Plan says the records indicate that the enrollee cannot 
take Methotrexate. The Plan also says that the criteria requires that the requested drug be taken in combination 
with Methotrexate. 
 
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 Avsola. Our reviewer says that the 
requested use of Avsola is not medically necessary. Our physician reviewer found the requested use of Avsola (without concomitant methotrexate) is not Food and Drug Administration-approved for the enrollee's 
diagnosis. The reviewer found that the use of Avsola (without concomitant methotrexate) is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
Therefore, the reviewer found that the requested use of Avsola 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 Avsola have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avsola (Q5121).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted living facility (ALF) visit provided on August 8, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON ALF visit. You say that the enrollee's insurance changed from Original 
Medicare, and you were not informed in time to request authorization. The Plan denied your request. The Plan 
says the services at issue were non-emergent and provided OON without authorization. This was correctly 
denied. 
 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 not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 assisted living facility (ALF) visit provided on 
August 8, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing of 22 or more classes provided on July 3, 2023.  
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the number of definitive urine drug classes is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive urinary drug testing may be covered 
under certain clinical circumstances.  
 
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 drug testing. Our reviewer says that this 
testing does not meet criteria for payment. Our physician reviewer found that Medicare covers definitive UDT 
if screening test results are positive or inconsistent with prescription medications, dosing schedules, or history 
and expected results. There is nothing in the medical record to suggest that there was a need to utilize definitive 
urine drug testing 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing of 22 or more classes provided on July 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says the CardioMEMS device is considered unproven and 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 pre-approve CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (CardioMEMS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of inpatient care provided from March 3, 2022, 
to March 6, 2022 and March 9, 2022, to March 10, 2022. 
 
You asked the Plan to pay for continuation of inpatient care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says the inpatient care was 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 continuation of inpatient care provided from 
March 3, 2022, to March 6, 2022 and March 9, 2022, to March 10, 2022. Our reviewer says that the requested 
inpatient care is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that requested inpatient care at issue in this case was not medically reasonable or necessary as the enrollee was 
hemodynamically stable and the days in question required no inpatient diagnostic studies or therapeutic 
interventions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of inpatient care provided from March 3, 2022, to March 6, 2022 
and March 9, 2022, to March 10, 2022 have not been met. Therefore, we decided that the Plan does not have to 
pay for continuation of inpatient care provided from March 3, 2022, to March 6, 2022 and March 9, 2022, to 
March 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services. 
 You asked the Plan to pre-approve home health services. You say that the enrollee is unable to drive, and the 
services are medically necessary. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. The enrollee is not homebound. 
 
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 home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve-in-valve replacement 
(SESAME + valve-in-MAC TMVR). 
 
You asked the Plan to pre-approve SESAME + valve-in-MAC TMVR. 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 SESAME + valve-in-MAC TMVR. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while studies of SESAME + valve-in-MAC TMVR have suggested clinical 
benefit in select patient groups, studies examining long-term efficacy remain to be completed. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit.. At the 
current time, the SESAME + valve-in-MAC TMVR would not be considered medically necessary in 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 SESAME + valve-in-MAC TMVR have not been met. Therefore, we decided 
that the Plan does not have to pre-approve transcatheter mitral valve-in-valve replacement (SESAME + valve-
in-MAC TMVR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abiraterone tablets. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 abiraterone tablets.   
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure with an ear, nose, and throat (ENT) 
specialist to be provided by an out-of-network (OON) provider with an in-network exception. 
 
You asked the Plan to pre-approve a surgical procedure. You say that you have a tumor that needs to be 
removed and the physician you were seeing previously retired. There is no other provider that can perform this 
surgery. The Plan denied your request. The Plan says you must use network providers to get your medical care 
and services. There are in-network providers who can provide the requested service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a surgical procedure with an ear, nose, and throat (ENT) specialist to be provided by an out-of-network (OON) 
provider with an in-network exception.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that genicular artery embolization is 
medically necessary. The Plan denied your request. The Plan says there is a lack of peer-reviewed medical 
literature to support genicular artery embolization over traditional treatment of knee pain due to osteoarthritis. 
There is limited published, large-scale, long-term peer-reviewed literature that shows this procedure is a safe 
and effective treatment for knee pain due to osteoarthritis. Further investigation is needed to prove that 
genicular artery embolization is as good or better than standard treatments for knee pain due to osteoarthritis. 
 
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 genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and necessary. Our physician reviewer found genicular artery embolization is considered 
experimental/investigational therapy. There are open, recruiting, current clinical trials for this therapy 
(NCT04472091, NCT04379700, NCT04682652, NCT04951479, and NCT05349685). 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 16, 
2023, to January 17, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says it was not expected that the enrollee's necessary 
hospital care would span at least 2 midnights. 
 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was admitted on January 16, 2023 for chest pain and epigastric pain. 
Electrocardiogram was unremarkable and troponin x 2 were normal. The admission plan was for cardiac stress 
testing and cardiology evaluation. The record does not show that at the time of inpatient admission the 
admitting physician would have reasonable expected the enrollee's necessary hospital care to span at least 2 
midnights. 
 
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 pay for the acute inpatient hospital care provided from January 16, 2023, to January 17, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the request for Prolia was denied. You say that you are 
not exactly why. You also say that you would like someone to reach out to your provider to advise. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, one oral 
bisphosphonate (such as alendronate, risedronate) and one intravenous bisphosphonate therapy (such as 
zoledronic acid), zoledronic acid. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Prolia have been met. Specifically, 
there were no medical records provided. The case file shows that the Plan reached out to your provider to 
obtain these medical records but did not receive them. The case file shows that the providers office chose not 
to submit medical records because you were already scheduled to start treatment with the preferred drug 
Alendronate. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
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 that this is medically necessary. The Plan 
denied your request. The Plan says that the enrollee's continued care needs can be met in another setting. 
 
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 that at the time of the request for LTACH services, per the most recent progress notes 
from December 04, 2023, the enrollee is medically stable. The enrollee does not require services at the LTACH 
that are not available at the acute care hospital where he/she is currently receiving care. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 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.