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

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 You asked the Plan to pre-approve Evenity. You say that the enrollee has an appointment to have this injection 
done. The Plan denied your request. The Plan says the enrollee does not have any stated contraindications to 
the preferred products, nor have they tried any of the preferred agents. The Plan also says that a rationale for 
use of the non-preferred product is not provided for safety or efficacy. 
 
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 Evenity. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found the enrollee has not tried and failed 
the required drug(s). Our reviewer also found that there is no documentation provided indicating that the Plan's 
required drug(s) 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 
(36475). 
 
You asked the Plan to pre-approve endovenous ablation therapy of incompetent vein. You say that this is 
medically necessary. The Plan denied your request. The Plan says this request is not medically necessary 
because the records show the therapy is requested for treatment of perforator veins and not for the lesser or 
greater saphenous veins or their tributaries. 
 
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 endovenous ablation therapy of 
incompetent vein. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is no documentation that the enrollee is having 
significant symptoms attributable to the veins in question. There is no documentation of an ulceration at the 
location of the perforator veins. The enrollee has undergone numerous endovenous procedures bilaterally. Also 
agree with health plan determination that a cohesive plan regarding what vein is to be treated and how that 
relates to any symptoms is not provided. Regardless, in the absence of a non-healing ulcer, the medical 
necessity for ablation of perforator veins would be difficult to justify in this 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 endovenous ablation therapy of incompetent vein have not been met. Therefore, 
we decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 
(36475).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an ultra-lightweight wheelchair with accessories. 
 
You asked the Plan to pre-approve the wheelchair and accessories. The Plan denied your request. The Plan says 
that the coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that an ultra lightweight wheelchair and accessories are 
covered for the indications established in the applicable LCD. 
 
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 wheelchair and accessories. Our 
reviewer says that the requested ultra lightweight wheelchair and accessories are medically reasonable and 
necessary. Our physician reviewer found that Medicare a high strength lightweight wheelchair is covered when 
a beneficiary is able to self-propel the wheelchair while engaging in frequent activities in the home that cannot 
be performed in a standard wheelchair or the beneficiary requires a seat width, depth, or height that cannot be 
accommodated in a standard, light weight or hemi-wheelchair, and spends at least two hours per day in the 
wheelchair. A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration 
of need is less than three months. In this case, the documentation supports the medical need for the requested 
ultra-lightweight wheelchair with accessories. 
 
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 wheelchair and accessories have been met. Therefore, we decided that the 
Plan has to pre-approve an ultra-lightweight wheelchair with accessories.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial and requesting 
consideration. The Plan denied your request. The Plan says you do not meet the requirements. The Plan says 
that the 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 your 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA), nerves innervating the 
sacroiliac (SI) joint, with image guidance (64625). 
 
You asked the Plan to pre-approve RFA to the sacroiliac joint. You say that this is medically necessary. The 
Plan denied your request. The Plan says this 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 RFA to the sacroiliac joint. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding imaging or radiographic 
evidence supporting pathology of the bilateral sacroiliac joints. There is no clear history of SI joint pain onset 
or failure of conservative treatment directed to the SI joint outside of injection. Additionally, multiple other 
plausible pain generators including at the lumbosacral spine are evident. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA to the sacroiliac joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA), nerves innervating the sacroiliac (SI) joint, 
with image guidance (64625).
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 64493-50 and J3490. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 64494-LT and 
64494-RT.  
 
You asked the Plan to pay for procedure codes 64494-LT, 64494-RT, 64493-50 and J3490. You say that you 
would like the Plan to reconsider their denial of payment. The Plan says that the services are not covered as 
billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 64493-50 and J3490.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 64493-50 and J3490.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
64494-LT and 64494-RT. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. 
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 64494-LT and 64494-RT have not been met. Therefore, we decided that the Plan does not 
have to pay for the services described by procedure code(s) 64494-LT and 64494-RT. 
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee.  
The Plan denied your request. The Plan says that the enrollee's records did not show the need for daily therapy 
services (physical, occupational, and/or speech therapy) and that these skilled services can be provided only on 
an inpatient basis in a SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have documented skilled therapy needs, appears to be functioning 
below her baseline, after being treated for a fracture, complicated by prolonged immobilization and blood clots.  
Daily skilled services are required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimerli (Q5128). 
 You asked the Plan to pre-approve Cimerli. The Plan denied your request. The Plan says there is no record that 
shows the enrollee has tried the preferred drug Byooviz and it has not worked, or that the enrollee has medical 
reasons that prevent them from using it. 
 
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 Cimerli. Our reviewer says that the 
enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has not tried and 
failed the required drug. Our reviewer also found that there is no documentation provided indicating 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 Cimerli have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cimerli (Q5128).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets medical 
necessity for transfer to LTACH for ongoing ventilator weaning, medical management and pulmonary support. 
The Plan denied your request. The Plan says the enrollee remains unstable; it is not safe to leave the hospital at 
this time. Care is being provided in the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service January 25, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports medical necessity. 
The Plan denied your request. The Plan says a complete order for the billed code was not included. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there are 
insufficient medical records to show that the testing of 22 or more drug classes was ordered based on 
medication side effects, suspicious behavior, or a change in behavior. The file shows that the Plan made 
multiple attempts to obtain additional information with no success. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code G0483 billed for date of service January 25, 2023.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says services that would be provided in the LTACH are being 
provided in the current acute care setting which is already approved. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a ventilator provided on January 21, 2023. 
 You asked the Plan to pay for ventilator. You say that this was medically necessary. The Plan denied your 
request. The Plan says the record fails to indicate that the ventilator was needed for a use other than positive 
airway pressure therapy. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for ventilator. Our reviewer says that this 
ventilator does not meet criteria for payment. Our physician reviewer found the record shows that this 
ventilator was 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 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 ventilator have not been met. Therefore, we decided that the Plan does not have 
to pay for a ventilator provided on January 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablets. 
 
You asked the Plan to pre-approve the medication. 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 drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ondansetron tablets.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that the codes billed are the most appropriate for the 
services. 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. The billed codes are not supported. The panel testing was not billed 
with a single code as required. The claim was billed with the laboratory POS code. The records do not support 
that the sample was taken in a laboratory setting. 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 the 
lab services provided on March 22, 2023.