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

 
We decided that the Plan does not have to pre-approve Trelstar Mixject for suspension 22.5mg. 
 
You asked the Plan to pre-approve the services. You say that Lupron is not an alternative. The Plan denied your 
request. The Plan says there is no evidence that the preferred alternatives were not appropriate.  
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 the services. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that there is no 
indication that the enrollee has tried and failed Lupron. Based on the medical records provided and the 
Medicare-approved major drug compendia there is no indication that the plan's required drug 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Trelstar Mixject for suspension 22.5mg.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent of the genicular nerve 
branches. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven for the treatment of knee 
pain. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered an experimental and investigational procedure which is the subject of ongoing 
clinical trials. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent of the genicular nerve branches.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is a fall risk and cannot talk care of 
themself. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have 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 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Woundfix. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have chronic 
pressure wounds. The previous types and duration of care are not known. It appears the wounds currently need 
basic debridement. The enrollee's bedbound status limits/prevents basic offloading of the wounds. The 
requested Woundfix is not reasonable or medically necessary based on the submitted records. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Woundfix.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drug, bevacizumab. The records do not show that the required drug would be contraindicated or 
less effective; therefore, Lucentis is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lucentis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the temporary percutaneous epidural implantation of the 
neurostimulator electrode array (63650) and implantable neurostimulator electrode, each (L8680). 
 
You asked the Plan to pre-approve the services. You say that this should be a covered service. The Plan denied 
your request. The Plan says this request 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has not had prior back surgery or a surgical consultation. The enrollee does not 
have an evidence-based indication for a spinal cord stimulation (SCS) trial. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the temporary percutaneous epidural implantation of the neurostimulator electrode array 
(63650) and implantable neurostimulator electrode, each (L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with an oncologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you need a second opinion and an x-ray. You 
have been trying to get chemotherapy treatment since May. You live five minutes from the hospital which 
makes it more convenient and easier to go to The Plan denied your request. The Plan says the request for a 
higher level of care must be an emergency or not available in-network. A second opinion consultation is 
available in-network and in your local area. 
 
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 
an office visit (99204) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. If this enrollee has chronic carbon dioxide (CO2) retention, they may benefit from bilevel positive 
airway pressure (BiPAP) during sleep. The records do not show that this has been tried and failed. Medicare 
does not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or when used at 
settings that can be provided with BiPAP. 
 
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 ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has idiopathic pulmonary fibrosis and bronchiectasis with restrictive lung disease. He is being treated for lung transplantation. 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. The services are therefore not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on January 6, 2023. 
 
You asked the Plan to pay for an x-ray. You say that this was billed with an appropriate place of service. The 
Plan denied your request. The Plan says this was not billed correctly as the enrollee was inpatient at the time of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing 
services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital Place of 
Service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. 
 
We looked at the file and Medicare rules. The record shows that the enrollee was inpatient at the time of 
service, but the service at issue was billed with an outpatient POS. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for an x-ray provided on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 00532 rendered on 
January 5, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 7, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of procedure code 00532 rendered on 
January 5, 2023.
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 the enrollee requires IRF services in order give them 
the best chance to return home with their previous level of independence. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 6, 2022, to 
October 14, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 6, 2022. The NOA was not received by the Plan until November 
14, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 6, 2022, to October 14, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for food expenses related to a transplant for dates of service 
September 16, 2022, to October 12, 2022. 
 
You asked the Plan to pay for the food expenses. You say that the Plan did not pay for any meals during this 
transplant. The Plan denied your request. The Plan says meals are not covered under the transplant benefit.  
Only travel and lodging are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that when a Medicare Advantage (MA) Plan provides 
transplant services at a more distant location, the MA plan must provide reasonable transportation for the 
enrollee and a companion to the distant facility; and provide reasonable accommodations for the enrollee and a 
companion while in the distant location for medical care.  
 
There is no provision in Medicare rules for coverage of transplant-related meals.  In addition, the Plan's 
Evidence of Coverage does not list meals as a covered benefit for transplants, only travel and lodging.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the food expenses have not been met. Therefore, we decided that the Plan does not have to pay for 
food expenses related to a transplant for dates of service September 16, 2022, to October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services billed with code 99490 for 
date of service February 16, 2022. 
 
You asked the Plan to pay for code 99490. You say that these services were provided to the patient and should 
be paid. The Plan denied your request. The Plan says you have not billed an appropriate initiating visit. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for chronic care management services to 
be covered, Medicare requires an initiating visit for new patients or patients who the billing practitioner hasnt 
seen within 1 year.  
 
In this case, the service in dispute (99490) is a chronic care management service.  There is no evidence that this 
provider provided an initiating visit, which is required in order to bill for chronic care management services. 
The records show that the patient enrolled in your chronic care management service on January 26, 2021.  
There is no evidence that the patient had been seen by this provider for more than a year before the services in dispute were billed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99490 have not been met. Therefore, we decided that the Plan does not have to pay for 
chronic care management services billed with code 99490 for date of service February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Afirma Assay by Veracyte genetic testing (81546) provided 
on November 8, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the requested testing is a billable code. The testing 
is medically necessary for the treatment of the enrollee. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the Afirma test meets criteria for analytical and 
clinical validity, and clinical utility as a reasonable and necessary Medicare benefit when patients with one or 
more thyroid nodules have a history or characteristics of malignancy.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee has signs for thyroid cancer 
such as thyroid nodules that have grown over time, a family history of thyroid cancer, difficulty swallowing or 
hoarse voice or have a history of exposure to radiation. Based on this information, we decided that Medicare 
rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to 
pay for Afirma Assay by Veracyte genetic testing (81546) provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs HF system was 
approved by the Food and Drug Administration (FDA) in 2014. Nonetheless, 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 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure (HF) system.