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

 
We decided that the Plan does not have to pre-approve Inflectra. 
 You asked the Plan to pre-approve Inflectra. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs Enbrel, Humira, 
Kevzara, Rinvoq, Xeljanz,or Xeljanz XR.  
 
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 Inflectra. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives 
Enbrel, Humira, Kevzara, Rinvoq, Xeljanz or Xeljanz XR. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements 
of the coverage criteria are not satisfied. 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 Inflectra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Inflectra.
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 requires rehab to get back to their 
baseline. The Plan denied your request. The Plan says the enrollee does 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 the enrollee does 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair (K0837) and 
additional items and accessories (codes E2361 x2, E1002, E1012, E1028, E2311, K0108, and E2623). 
 
  You asked the Plan to pre-approve a group 2 heavy duty power wheelchair and additional items and 
accessories. You say that the enrollee is limited in their MRADLs due to shortness of breath and decreased 
activity tolerance. You also say that if the enrollee attempted distances beyond 61 feet with a front wheeled 
walker or cane, it would result in them being at risk for falls. The Plan denied your request. The Plan says 
while the request for this power wheelchair for long-distance mobility and social activities in the community 
would add to the enrollee's independence, it is not required for mobility-related activities of daily living at 
home, and is not medically necessary. 
 
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 a group 2 heavy duty power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. 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. Our 
reviewer also found that there is no indication the enrollee is unable to use an alternative assistive device. 
 
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 group 2 heavy duty power wheelchair and additional items and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy duty 
power wheelchair (K0837) and additional items and accessories (codes E2361 x2, E1002, E1012, E1028, 
E2311, K0108, and E2623).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Anser VDZ testing (82542) provided on October 21, 2022.  
 
You asked the Plan to pay for the Anser VDZ testing. You say that this testing was ordered to help determine 
personalized solutions for managing loss of response to vedolizumab. The Plan denied your request. The Plan 
says that the clinical value and effectiveness of Anser VDZ testing the setting of Entyvio therapy have not been 
demonstrated in the peer-reviewed literature.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Anser VDZ testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that drug trough and antibody testing is endorsed by national clinical guidelines for patients 
who lose clinical response to biologics in inflammatory bowel 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 Anser VDZ testing have been met. Therefore, we decided that the Plan has 
to pay for the Anser VDZ testing (82542) provided on October 21, 2022.   
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for August 8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99285 is not supported by the submitted records. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
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 these services. Our reviewer says that procedure code 99285 
is not supported by the submitted records. Our reviewer found the enrollee was treated in the emergency 
department on August 8, 2022. The provided note states the enrollee reported epigastric pain starting the night 
before with a stabbing quality. The physical findings were comprehensive and revealed soft, tender abdomen, 
no guarding. Vitals were stable. Labs were essentially normal. The note included a comprehensive history and 
physical; however, there was no support for medical decision-making of high complexity as there was no active 
bleeding, vitals were stable, treatment was not complex, and the enrollee was overall low-risk. Therefore, the 
code, 99285 is not sufficiently supported.  
 
We looked at this coder'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 pay for procedure code 99285 billed for August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endovenous ablation. 
 
You asked the Plan to pre-approve the endovenous ablation.. The Plan denied your request. The Plan says the 
endovenous ablation 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 the endovenous ablation. Our reviewer 
says that the endovenous ablation is not medically necessary. Our physician reviewer found that the records do 
not reveal the results of lower extremity venous ultrasound exam. There is insufficient documentation to 
support the medical necessity for the requested endovenous ablation therapy in the enrollee's 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 the endovenous ablation. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the endovenous ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx provided on March 6, 2023.  
 
You asked the Plan to pay for the FoundationOne Liquid CDx. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically 
necessary because the records do not show that the enrollee is considering further treatment.  
 The Plan follows Medicare rules. Medicare rules say that this testing is covered when the enrollee has decided 
to seek further cancer 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 pay for the FoundationOne Liquid CDx. Our 
reviewer says that that the enrollee had relapsed stage IV cancer and had not previously been tested with Liquid 
CDx. However, it was documented not to want any further cancer treatment. Thus, the criteria for coverage are 
not met. Our physician reviewer found  
 
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 FoundationOne Liquid CDx have not been met. Therefore, we decided that 
the Plan does not have to pay for the FoundationOne Liquid CDx provided on March 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary as you are very 
weak and unable to walk. The Plan denied your request. The Plan says that 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 months of continued coverage continuous positive 
airway pressure (CPAP) device (E0601) and heated humidifier (E0562). 
 
You asked the Plan to pre-approve continued use of ventilator. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says the records do not support that 
the additional 4 months is 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 continued use of ventilator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the requested 4 months of continued CPAP is not medically necessary. 
This enrollee has obstructive sleep apnea, on CPAP.  Initially CPAP was denied by the plan because medical 
records were not received, but the Plan subsequently located the medical records and approved the device for 3 
months, pending a new compliance report.  According to the notes from the clinical visit on March 20, 2023, 
the last positive airway pressure (PAP) titration was May 23, 2022. The enrollee has a new device with a higher 
pressure at 17 centimeters (cm) of water. The enrollee was having difficulty tolerating the new device, with a 
reported compliance of 10%. There is no subsequent clinical evaluation and no more recent compliance 
assessment. Without documentation of sufficient usage of and benefit from the device, the denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 4 months of continued coverage continuous positive airway pressure (CPAP) 
device (E0601) and heated humidifier (E0562).
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 enrollee does not meet Medicare guidelines for 
services in 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 the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 this patient 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 pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a sacroiliac joint 
injection 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 the injection. Our reviewer says that a 
sacroiliac joint injection i snot medically necessary. Our physician reviewer found that there is no 
documentation of at least three tests that were positive for sacroiliac joint pain. Therefore, the enrollee does not 
meet the LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve a sacroiliac joint injection. You say that you cannot have surgery because of 
your spine and need to have the shot to help with everyday activities. The Plan denied your request. The Plan 
says a sacroiliac joint injection 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 a sacroiliac joint injection. Our 
reviewer says that a sacroiliac joint injection is not medically necessary. Our physician reviewer found that you 
have low back pain, radicular and axial pain. You have had epidural steroid injections and radiofrequency 
ablation of your medial branches. Additionally, there are not physical exams findings listed. Therefore, you do 
not meet the LCD coverage criteria. 
 
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 sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection.