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

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. 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. 
 
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 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for motion fluoroscopic evaluation of swallowing function by 
cine or video recording, radiologic examination, swallowing function, with cineradiography/videoradiography, 
including scout neck radiograph(s) and delayed image(s), when performed, contrast (e.g., barium) study, 
radiologic examination, spine, cervical; 2 or 3 views, radiologic examination, chest; single view and radiologic 
examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when 
performed; single contrast (e.g., barium) study provided on January 19, 2023. 
 
You asked the Plan to pay for motion fluoroscopic evaluation of swallowing function by cine or video 
recording, radiologic examination, swallowing function, with cineradiography/videoradiography, including 
scout neck radiograph(s) and delayed image(s), when performed, contrast (e.g., barium) study, radiologic 
examination, spine, cervical; 2 or 3 views, radiologic examination, chest; single view and radiologic 
examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when 
performed; single contrast (e.g., barium) study. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were performed at a nursing home (via mobile van/portable x-
ray), which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of motion fluoroscopic evaluation of swallowing function by cine or video recording, radiologic 
examination, swallowing function, with cineradiography/videoradiography, including scout neck radiograph(s) 
and delayed image(s), when performed, contrast (e.g., barium) study, radiologic examination, spine, cervical; 2 
or 3 views, radiologic examination, chest; single view and radiologic examination, upper gastrointestinal tract, 
including scout abdominal radiograph(s) and delayed image(s), when performed; single contrast (e.g., barium) 
study have not been met. Therefore, we decided that the Plan does not have to pay for motion fluoroscopic 
evaluation of swallowing function by cine or video recording, radiologic examination, swallowing function, 
with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when 
performed, contrast (e.g., barium) study, radiologic examination, spine, cervical; 2 or 3 views, radiologic 
examination, chest; single view and radiologic examination, upper gastrointestinal tract, including scout 
abdominal radiograph(s) and delayed image(s), when performed; single contrast (e.g., barium) study provided on January 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dexamethasone and Prochlorperazine.  
You asked the Plan to pre-approve the medication. You say that the requested drugs are medically necessary. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug dexamethasone requested here is not among the types which 
are covered by Medicare Part B. Although an oral anti-emetic such as Prochlorperazine may be covered by 
Medicare Part B, this request does not fall under Medicare Part B coverage because it is not being used as a full 
therapeutic replacement for intravenous anti-emetics during a particular chemotherapy regimen. Therefore, we 
decided that the Plan does not have to pre-approve dexamethasone and Prochlorperazine.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the 
requested device. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) from an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that the enrollee needs to be taught how to use the 
device. The Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (PCD) from an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services from an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that the network providers are registered nurses and 
the enrollee needs more intense therapy. The Plan denied your request. The Plan says the services are available 
from network providers. 
 
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. The network providers are qualified 
Registered Nurse Practitioners. 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 outpatient mental health 
services from an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided November 14, 2020, to 
November 17, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that based on the enrollee's condition, and 
inpatient admission was medically necessary The Plan denied your request. The Plan says that the enrollee's 
medical needs could have been provided as outpatient services. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided November 14, 2020, to November 17, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve these services. You say that your current bed is not conducive to your 
independence and rehabilitation. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
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 records provided support medical 
necessity. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on December 13, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 the testing services rendered 
on December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered 
January 20, 2023. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the test panel is a single test with multiple components 
and is characterized by a single unit of service (UOS =1).  
 
We looked at the file and Medicare rules. The file shows that the services were not billed as a single unit of 
service. 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 the urine polymerase chain reaction (PCR) 
panel rendered January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics billed with codes L3000-LT-KX and L3000-
RT-KX for January 18, 2023. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 the orthotics billed with codes L3000-LT-KX and L3000-RT-
KX for January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneDose genetic response report and hereditary genetic 
cardiac test panel provided December 5, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you believe that the treatment sought was 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says the enrollee does not meet the 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is unclear documentation and need for the testing. There is no family history of 
heart disease and ordering the GeneDose genetic response report (comprehensive hereditary pharmacogenomic 
testing) and the hereditary genetic cardiac test panel just for polypharmacy is not 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for GeneDose genetic response report and hereditary genetic cardiac test panel provided 
December 5, 2022.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records show that it is not reasonable to expect to 
safely, actively, participate in, nor fully benefit from, the intensity of services of an IRF. Services needed may 
be provided safely in a lower level of care. 
 
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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) lung cancer 
screening provided on February 9, 2023.  
 
You asked the Plan to pay for the LDCT testing. You say that this was billed with an appropriate diagnosis and 
should be paid.  The Plan denied your request. The Plan says this was not billed with a valid diagnosis code.  
 
The Plan must follow Medicare rules. Medicare rules say that LDCT lung cancer screening claims will be 
denied when they are not billed with diagnosis code Z87.891, F17.210, F17.211, F17.213, F17.218, or F17.219. 
 
We looked at the file and Medicare rules. The only diagnosis code reported on this claim is Z12.2. Based on this information, we decided that Medicare rules for coverage of the LDCT testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the low dose computed tomography (LDCT) lung 
cancer screening provided on February 9, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements. Services needed may 
be provided safely in a lower level of care. 
 
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. 
 
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.