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

 
We decided that the Plan does not have to pre-approve Botox. 
 You asked the Plan to pre-approve Botox. 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 Botox. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of spasmodic torticollis. The documentation does not support that the 
enrollee has tried and failed Dysport and Xeomin. The documentation does not support that Dysport and 
Xeomin would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet evidence-based criteria. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging shows spinal stenosis. The cause of back pain is not 
clear. 
  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the specialist office visit and the synvisc 
injections provided on October 21, 2022. 
 
You asked the Plan to reduce the cost share for the specialist office visit and the injections. You say that you 
paid a $45 copayment in the past. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each Medicare-covered specialist visit. Your contract with the Plan clearly says that you must 
pay 20% coinsurance of the allowed amount for Part B-covered drugs. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. 
 
You have also been asked to pay $97.34, which is 20% coinsurance of the allowed amount for each injection. 
You have been asked to pay a total of $194.68 for the injections ($97.34 coinsurance x 2 injections = $94.68). 
These items/services fall within the Medicare Part B prescription drugs benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the cost share for the specialist office visit and the synvisc injections provided on 
October 21, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Amvuttra. 
 
You asked the Plan to pre-approve Amvuttra. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the requested drug is not medically necessary. 
 
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 Amvuttra. Our reviewer says that the 
documentation supports that the requested drug is medically reasonable and necessary. Our physician reviewer 
found the enrollee has a diagnosis of polyneuropathy secondary to hereditary transthyretin-mediated 
amyloidosis. The Food and Drug Administration has stated that the requested drug is indicated for the 
enrollee's condition. Therefore, the enrollee meets 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 Amvuttra have not been met. Therefore, we decided that the Plan has to pre-
approve Amvuttra.  
 
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: 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 for you to 
receive the level of care needed. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an IRF.  
 
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 injections. 
 
You asked the Plan to pre-approve injections. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that injections are only covered for certain indications. 
 
 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 injections. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found you have chronic low back pain. You are doing a home exercise program. You had a 
sacroiliac joint injection on March 31, 2023, and a lumbar facet intra-articular injection on April 4, 2023. The 
pain relief is noted to be 60%. Since the required level of relief did not occur, the request is considered not 
medically reasonable and necessary. Therefore, you do not meet criteria for the requested injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injections.
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 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 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 detailed documentation is not evident regarding a significant past and/or 
current medical history that would place this enrollee at increased risk for peri-surgical complications requiring 
an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the record does not show that the admitting 
physician reasonably would expect the enrollees necessary hospital care would span two 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 pre-approve acute inpatient hospital care.
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 need extra help with being able to live day to 
day. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.  
 
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 your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you 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 you 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care and is currently unstable for transfer to an LTACH. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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. You say that you are bedbound and need a SNF to regain 
strength. The Plan denied your request. The Plan says your records do not show that you have a need for skilled 
nursing or therapy services daily that have to be delivered on an inpatient basis. Services needed may be 
provided safely in a lower level of care. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 11, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says upper limb strength and function are adequate for the member to be able to control 
the power options using their own switches which are included in the allowance of these power options. 
 
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 accessories. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is able to eat and groom independently. The enrollee has adequate strength to manage 
the standard power drives. This is not medically necessary to meet the enrollee's needs. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection between wheelchair controller and two or more power seating 
system motors (E2311), a harness (E2313), and an expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel (81456). 
 
You asked the Plan to pre-approve a targeted genomic sequence analysis panel. 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 genomic sequence analysis panels are covered under 
certain 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 pre-approve a targeted genomic sequence analysis 
panel. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
records submitted indicate that the provider is requesting an additional code for a procedure that is part of 
another test that was performed called Tempus xT. These two tests can't be billed together (they are mutually 
exclusive procedures). The review has determined that the enrollee does not meet the coverage criteria detailed 
in the LCD. 
 
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 targeted genomic sequence analysis panel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel (81456).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home non-invasive ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the doctor wants you to have this equipment. The 
Plan denied your request. The Plan says thi sis not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
requested ventilator is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease. The record indicates that the enrollee requires bi-level in intelligent volume-assured pressure support 
(IVAPS) mode. The provided primary source documentation does not contain sufficient detailed information in 
the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
average volume-assured pressure support (AVAPS) capability and failure of such a device has not been 
documented. The elements of the coverage criteria are not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home non-invasive ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life2000 system. 
 
You asked the Plan to pre-approve the system. You say that this is necessary to help manage complicated 
respiratory needs at home. The Plan denied your request. The Plan says a review of the current medical 
literature does not consider this device to be standard medical treatment. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 system. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the Life2000 
system is not a true ventilator because it is not capable of providing full ventilatory support. It is intended to be 
used during activity, and there is inadequate evidence that it is beneficial in the treatment of any chronic lung 
disease. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Life2000 system.