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

 
We decided that the Plan does not have to pre-approve inclisiran (J1306). 
 
You asked the Plan to pre-approve inclisiran. The Plan denied your request. The Plan says inclisiran is not 
medically necessary. 
 
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 inclisiran. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found there is no documented evidence of 
atherosclerotic cardiovascular disease. As such, the patient does not meet current guideline criteria for drug 
use. Our reviewer also found that there is insufficient documentation to support the medical necessity for the 
use of the proprotein convertase subtilsin-kexin type 9 (PCSK9) inhibitor, inclisiran, in this patients 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 inclisiran have not been met. Therefore, we decided that the Plan does not have 
to pre-approve inclisiran (J1306).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you have received treatment with Euflexxa in the 
past. You say that it was always pre-authorized. You also say that you do not know why it was denied this 
time. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Orthovisc or Supartz FX. 
 
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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
mention contraindications or reasons the preferred medications were not considered or that the Plan's additional 
required drugs would likely be less effective and/or likely have adverse effects. Therefore, the reviewer found 
that the request for Euflexxa 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 2, 2023. 
 You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is covered 
by Medicare. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier in the proper location on the claim. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Specifically, the rules require that this Z-code be reported in the SV101-7 (5010A1-837P) or 
SV202-7 (5010A1-837I) claim line detail field. In this case, you placed the Z code in 24-S (the remarks, line-
level) field. This is not the proper location for this code. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services provided on August 2, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 CDx testing (81479) provided on August 18, 2023. 
 
You asked the Plan to pay for Guardant360 CDx testing. You say that this test was medically necessary and 
was reported appropriately. The Plan denied your request. The Plan says that the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx testing 
have been met. Therefore, we decided that the Plan has to pay for Guardant360 CDx testing (81479) provided 
on August 18, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you would like to request reconsideration of the 
denied PET scan and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record provided does not establish that 
the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal dementia or that the 
examination is being requested in the context of a clinical trial. 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee cannot take oral iron because of 
their gastric bypass. The Plan denied your request. The Plan says that step therapy requirements have not been 
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 the medication. Our reviewer says that 
the criteria for coverage of Feraheme have not been met. Our physician reviewer found that the Plan requires a 
trial of Infed before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the Plan's required drug would likely be less 
effective 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
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 would benefit from short term IRF 
rehabilitation to improve functional mobility, activities of daily living skills, and gait to reduce infection, acute 
care hospital admission, and caregiver burden. The Plan denied your request. The Plan says based on the 
available information, admission to IRF is not reasonable and necessary, as the enrollee's condition does not 
meet the Medicare rules.  
 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for coronary artery bypass grafting. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the ernollee 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 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 enteral formula (Glucerna 1 can/day 356cal/can) 
(B4154). 
 
You asked the Plan to pre-approve enteral formula. You say that you disagree with the denial. The Plan denied 
your request. The Plan says it is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve enteral formula (Glucerna 1 can/day 356cal/can) (B4154).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient partial colectomy with removal of terminal 
ileum with ileocolostomy (44205). 
 
You asked the Plan to pre-approve an inpatient partial colectomy. You say that the enrollee's colonoscopy 
revealed marked abnormality in the cecum with nodularity, as well as the ileocecal valve and terminal ileum. 
You say that biopsies revealed inflammatory changes without any malignancy. You also say that this surgery is 
indicated as the next course of action. The Plan denied your request. The Plan says a resection of the colon for 
a patient with benign biopsies would not be the standard of care and your providers can continue to monitor 
your condition with additional colonoscopies and other diagnostic procedures. 
 
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 an inpatient partial colectomy. Our reviewer says that the requested inpatient partial colectomy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records document multifocal polypoid 
dysplasia for which surgical resection is standard of care. The reviewer also found that the provided records do 
not clearly indicate that an inpatient level of care is medically necessary for the procedure. Therefore, the 
reviewer found that the requested inpatient partial colectomy 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 an inpatient partial colectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient partial colectomy with removal of terminal ileum with 
ileocolostomy (44205).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical radiographic 
images (D0220 and D0230), pulp vitality tests (D0460), and endodontic therapy (D3330) provided on July 31, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan should pay for this. The 
Plan denied your request. The Plan says these services have been processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0140 was exhausted on date of service March 21, 2023, and D0220 was exhausted on 
May 5, 2023. D0460 and D3330 are not covered dental benefits. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical radiographic images (D0220 and D0230), pulp 
vitality tests (D0460), and endodontic therapy (D3330) provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33210 billed for date of service June 20, 
2023.   
You asked the Plan to pay for procedure code 33210. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 33210 is bundled into 
payment for code 92933. 
 
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 33210 
is a column two code to column one code 92933 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 33210 billed for date of service June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual dental allowance amount was exhausted on date of service May 24, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on August 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis (L3960) provided on July 6, 2023. 
 
You asked the Plan to pay for the shoulder orthosis. You say that the item should be covered. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication this item was needed or ordered in the clinical documentation submitted. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the shoulder orthosis (L3960) provided on July 6, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 31, 2022, to 
September 3, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that N17.9 
(Acute kidney failure) was appropriately listed as the principal diagnosis. The Plan denied your request. The 
Plan says although the diagnosis N17.9 (Acute kidney failure) is documented, reasonable clinical evidence 
within the health record must be present to clinically validate the diagnosis. This patient with a history of 
chronic kidney disease (CKD) presented to the emergency room with hyperkalemia, a creatinine of 1.79mg/dL 
and in fluid overload. While it is noted that 1.79mg/dL is an elevated serum creatinine, this was not 1.5 times 
the patient's baseline. As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code N17.9 (Acute kidney 
failure). 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the billed principal diagnosis of N17.9 (Acute kidney failure) is 
not supported by the medical records. Our physician reviewer found the enrollee is an 83-year-old female with 
chronic kidney disease who was treated in the hospital. The enrollee's baseline creatinine was estimated to be 
1.37.  Her initial creatinine was 1.79 at the highest in the setting of fluid overload. There was insufficient 
evidence to support the diagnosis N17.9 (Acute kidney failure) for this admission. There was not a rise of 
creatinine off 1.5 times baseline, no creatinine of 4 or higher, and no significant oliguria. Her creatinine 
improved over 48 hours. Therefore, the criteria for acute kidney failure is not met, and the code, N17.9 is not 
sufficiently supported for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 31, 2022, to September 3, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit services provided on April 28, 2023. 
 
You asked the Plan to pay for home visit services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit services 
provided on April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a humidifier, heated, used with positive airway pressure device 
and continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve a humidifier and CPAP device. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that continued coverage of a PAP device (E0470 or 
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document 
that the beneficiary is benefiting from PAP therapy. 
 
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 humidifier and CPAP device. Our 
reviewer says that the services are medically necessary. Our physician reviewer found you have obstructive 
sleep apnea (OSA) and are compliant with CPAP therapy. Therefore, withdrawal of CPAP therapy would be 
substandard of care. Continued CPAP therapy is indicated. 
 
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 humidifier and CPAP device have been met. Therefore, we decided that the 
Plan has to pre-approve a humidifier, heated, used with positive airway pressure device and continuous positive 
airway pressure (CPAP) device.  
 
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.