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

 
We decided that the Plan does not have to pre-approve Botox  
You asked the Plan to pre-approve Botox. You say that the enrollee is having balance issues as their tremors 
are getting worse.  The Plan denied your request. The Plan says the 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. If a Plan decides to apply step therapy requirements to Part B drugs, they must 
disclose that information in the ANOC and EOC documents. The Plan's contract does not indicate that it has 
implemented such criteria for certain Part B medications. 
 
We looked at your contract with the Plan. We did not see where the contract says that the Plan has decided to 
apply step therapy requirements to Part B drugs. This means that the Plan did not follow Medicare rules for 
disclosure of step therapy information. Therefore, we decided that the Plan does not have to pre-approve Botox
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR) (33285). 
 You asked the Plan to pre-approve insertion of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for insertion of an implantable cardiac monitor (ICM) in this enrollees 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR) (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service February 13, 
2023. 
 
You asked the Plan to pay for procedure code 99358. You say that the enrollee was seen by different specialties 
on this date. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99358 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99358 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99358 billed for date of service February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and drug services rendered on February 9, 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that the OPPS status indicator identifies whether the 
service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged.  
 
We looked at the file and Medicare rules. Billed procedure codes 36415, 80053, 83615, 84439, 84443, and 
85025 have an OPPS status indicator of Q4 and are packaged laboratory services. Code J7040 has a status 
indicator of N and no separate payment. Code J9299 has a status indicator of K and is not packaged under 
OPPS. 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 laboratory and drug services rendered on 
February 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
 
 You asked the Plan to pre-approve the additional routine transportation miles. You say that you have no way to 
get to and from your home to the surgical area and back since this is an invasive procedure. You also would 
like an exception to the fifty mile limit for this procedure. The Plan denied your request. The Plan says the 
requested shortest route is 68 miles and you will have exceeded your benefit mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional routine transportation miles for your procedure. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional routine transportation miles.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and high-level office consultation (99205, 
99245) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit and high-level office consultation to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 and high-level office consultation (99205, 99245) to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0089U, 81345) provided on February 2, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for genetic testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for OON care have not been met. 
 
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 rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Additionally, we have confirmed that code 81345 is a column II code to column I code 0089U. This claim line 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria for code 81345 have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic testing (0089U, 81345) provided on February 2, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87631 billed for date of service December 
12, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says 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. Review of the claim does not show that the required unique identifier 
was reported. 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 87631 billed 
for date of service December 12, 2022.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve etoposide, cisplatin, palonosetron, dexamethasone and 
fosaprepitant. We decided that the Plan does not have to pre-approve aezolizumab. 
 
You asked the Plan to pre-approve aezolizumab, etoposide, cisplatin, palonosetron, dexamethasone and 
fosaprepitant. You say that this treatment is medically necessary. The Plan says that there is no data that 
supports the safety and/or efficacy of this regimen as requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use. 
 
We decided that the Plan has to pre-approve etoposide, cisplatin, palonosetron, dexamethasone and 
fosaprepitant. 
 
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 aezolizumab, etoposide, cisplatin, 
palonosetron, dexamethasone and fosaprepitant. Our reviewer says that etoposide is FDA-approved for the 
enrollees diagnosis. Etoposide and cisplatin are supported by the major drug compendia for treatment of 
limited stage small cell lung cancer and dexamethasone, palonosetron and fosaprepitant are indicated for 
chemotherapy-induced nausea and vomiting. Etoposide and cisplatin meet Medicare criteria for safe and 
effective and otherwise reasonable and necessary for treatment of limited stage small cell lung cancer. 
Dexamethasone, palonosetron and fosaprepitant meet Medicare criteria for safe and effective and otherwise 
reasonable and necessary for chemotherapy-induced nausea and vomiting. Therefore, we decided that the Plan 
has to pre-approve etoposide, cisplatin, palonosetron, dexamethasone and fosaprepitant. 
 
We also decided that the Plan does not have to pre-approve aezolizumab. 
 
Our physician reviewer says that the use of aezolizumab is not supported by one of the major drug compendia 
or by clinical research for limited stage small cell lung cancer. Atezolizumab does not meet Medicare criteria 
for safe and effective and otherwise reasonable and necessary for limited stage small cell lung cancer. 
Therefore, we decided that the Plan does not have to pre-approve aezolizumab 
 
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 the Freestyle Libre 2 continuous glucose monitor 
system. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 continuous glucose monitor system. You say that the 
Freestyle Libre 2 continuous glucose monitor system is medically necessary. The Plan denied your request. The 
Plan says the requested Freestyle Libre 2 continuous glucose monitor system does not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Freestyle Libre 2 continuous 
glucose monitor system. Our reviewer says that the requested Freestyle Libre 2 continuous glucose monitor 
system is not considered medically necessary in this case. Our physician reviewer found that the Medicare 
coverage criteria require that the enrollee be using insulin or have low blood sugar to qualify for CGM. This is 
not the case. There is no documentation as to why fingerstick monitoring would not suffice. CGM coverage 
criteria are not met. 
 
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 Freestyle Libre 2 continuous glucose monitor system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 2 continuous glucose 
monitor system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IGRT. 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary. The Plan denied your 
request. The Plan says IGRT 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 IGRT. Our reviewer says that the 
requested IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found IGRT is not medically necessary for treatment of this type of skin tumor. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve IGRT.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 30-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need wheelchair-
accessible rides to appointments. The Plan denied your request. The Plan says the requested trips exceed your 
transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
30-trip limit.
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 a home ventilator. You say that the patient requires a home ventilator for 
her stage 4 severe COPD. She has been using this device since 2019 and has had multiple hospitalizations. 
Other devices have proven ineffective. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary. The patient's needs can be met with a bilevel positive airway pressure (BiPAP) device 
with average volume-assured pressure support (AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic obstructive pulmonary disease. The medical records submitted on appeal indicates that she was 
previously prescribed a non-invasive ventilator (NIV). With this request for continuation of the NIV, dated 
June 7th, 2023, the device was ordered in VAPS mode. The compliance data submitted by the durable medical 
equipment provider from 2021 shows the device was being used in AVAPS-AE mode at that time, as well, and 
no other modes. She was evaluated by her provider in the office on May 3rd, 2023, and the office visit notes 
say she uses the device every night. The documentation submitted fails to indicate that she is requiring the NIV 
for use in other than bilevel positive airway pressure (BiPAP) or BiPAP with AVAPS mode. The records 
received do not say that the patient has failed the use of BiPAP or BIPAP with AVAPS when she is at her 
baseline level of breathing. The documentation provided does not support that the use of a BiPAP device with 
AVAPS would not meet the patient's current medical needs or has been found to be ineffective in the home 
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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 30-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
cancer treatments. The Plan denied your request. The Plan says the requested trips exceed your transportation 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
30-trip limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. Your current power wheelchair serves the same purpose as 
the requested power wheelchair. There is no documentation that anything is wrong with your current power 
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with a patient 
weight capacity 301 to 450 pounds (K0824) and 22nf sealed lead acid battery (E2361). 
 
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair and 22nf sealed lead acid battery. 
You say that you live in a facility that is huge and you are not able to get around with your walker anymore. 
You also say that your condition has gotten worse, you need more assistance to be mobile, and you do not have 
the strength to use a wheelchair that have to push yourself. The Plan denied your request. The Plan says the 
physician visit note from March 28, 2023, documents your weight to be 228 pounds. The Plan also says that he 
requested K0824 PWC is for weight capacity 301-450 pounds, and you do not meet the weight capacity for the 
requested K0824 PWC. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. Medicare rules also say if the base PWC is not 
covered, then related accessories will be denied.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 heavy duty power wheelchair and 22nf sealed lead acid battery have not been met. 
Specifically, the provided records show that your most recent documented weight is below the required weight 
limit of 301 to 450 pounds for the requested group 2 heavy duty power wheelchair (K0824). Therefore, we 
decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with a patient 
weight capacity 301 to 450 pounds (K0824) and 22nf sealed lead acid battery (E2361).