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

 
We decided that the Plan does not have to pre-approve Renflexis (Q5104). 
 You asked the Plan to pre-approve Renflexis. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Renflexis. 
 
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 Renflexis. Our reviewer says that the 
enrollee does not meet the coverage criteria for Renflexis. Our physician reviewer found the Plan requires a 
trial of Remicade, Inflectra, Infliximab or Simponi Aria before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drugs. Our reviewer also found that there is no 
documentation provided indicating that the Plans required drugs 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 Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis (Q5104).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla tablets (J8499). 
 
You asked the Plan to pre-approve Otezla. You say that Otezla has considerably helped the enrollee control 
their disease. You also say that you would like the Plan's decision to be reconsidered, and for continuation of 
Otezla to be approved for the enrollee. 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 Otezla tablets (J8499).  
 
Benefits for Otezla 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you fear that you are not stable enough to be alone 
and fear your life would be in danger as to how fast someone could get to you. You feel that Encompass has the 
best rehab in patient care and feels you could go home after the rehab provided there. The Plan denied your 
request. The Plan says the request is not medically necessary, the services you need can be provided safely in 
other settings, for example, a skilled nursing facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4630 billed for date of service December 2, 2022. 
 
You asked the Plan to pay for code A4630. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says code A4630 is considered bundled and not separately payable.  
 
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 A4630 has a status code of X on the Physician Fee Schedule. This means that 
procedure code A4630 is not payable under the physician fee schedule. Based on this information, we decided 
that Medicare rules for coverage of code A4630 have not been met. Therefore, we decided that the Plan does 
not have to pay for code A4630 billed for date of service December 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation trips 
(A0110). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you were recently 
diagnosed with breast cancer. As a result of this, you will have many upcoming appointments. The Plan denied 
your request. The Plan says additional trips would exceed your benefit 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 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
twenty (20) one-way transportation trips out of the allowed fifty (50) one-way trips approved. Once 50 trips are 
used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional non-emergent routine transportation trips (A0110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim. 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 benefit for the requested item or service was exhausted on date of service June 21, 2021. Therefore, 
we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tempus xF liquid biopsy (81455) provided on 
December 28, 2022. 
 
You asked the Plan to pre-approve the Tempus xF liquid biopsy. You say that this testing was medically 
necessary.  The Plan denied your request.  The Plan denied your request. The Plan says this test is not FDA 
approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that the Plan does not have to pre-approve the Tempus xF 
liquid biopsy (81455) provided on December 28, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 Injectafer. Our reviewer says that the 
coverage criteria are not met. Our physician reviewer found the Plan requires a trial of Venofer (iron sucrose) 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. 
Our reviewer also found that there is no documentation provided indicating that the Plans 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 3, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF liquid 
biopsy (81455) provided on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided on 
December 16, 2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that the enrollee was in dire need of 
this potentially lifesaving device. The Plan denied your request. The Plan says more than one calendar year 
from the date of service had passed before the claim was filed. The Plan also says that this claim was untimely, 
and the submission did not meet the exception criteria guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 The record shows that a claim for the automatic external defibrillator was not filed until January 17, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator (K0606) 
provided on December 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drug combination of Keytruda (J9271), carboplatin 
(J9045), and pemetrexed (J9305). 
 
You asked the Plan to pre-approve Keytruda, carboplatin, and pemetrexed. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that this drug regimen 
is not medically necessary for the enrollee's condition. 
 
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 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 Keytruda, carboplatin, and pemetrexed. 
Our reviewer says that the requested drug combination is not medically necessary, safe, and effective for the enrollee. Our physician reviewer found that the drug combination of Keytruda, carboplatin, and pemetrexed is 
not FDA-approved for the enrollees diagnosis in the setting of prior disease progression on another anti-
programmed cell death ligand-1 (anti-PD-L1) drug, Imfinzi. The requested drug combination is not supported 
by any of the drug compendia or by clinical research that appears in a Medicare-approved medical journal for 
the enrollee's diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, carboplatin, and pemetrexed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the drug combination of Keytruda (J9271), carboplatin 
(J9045), and pemetrexed (J9305).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo system implantation (0226T, C1825). 
 
You asked the Plan to pre-approve the Barostim Neo system implantation. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Barostim Neo system implantation. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service is considered experimental. 
 
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 Barostim Neo system implantation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Barostim Neo system implantation (0226T, C1825).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement; however, the documentation does not support that the 
enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours 
a week, under the supervision of a physician with at least three (3) visits weekly to regain or maintain the 
enrollee's functional status. The enrollee can receive further services at a lower level of care 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spine medial branch block (MBB) (64493, 
64494). 
 
You asked the Plan to pre-approve injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the medical records show that the enrollee does not meet all medical policy 
criteria. Criteria requires documentation that the enrollee's pain is predominantly axial, with absence of 
untreated radiculopathy (pain that travels due to nerve injury) or neurogenic claudication (leg pain, heaviness, 
and/or weakness due to compressed nerves) and that there is no non-facet pathology per clinical assessment or 
radiology study that could explain the source of the enrollee's pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain. He is s/p L2-L3 laminectomy in 8/22. He had an L4-L5 
interlaminar epidural steroid injection on December 5, 2022, and then a caudal epidural steroid on January 31, 
2023. The LCD requires the absence of untreated radiculopathy or neurogenic claudication and that there is no 
non-facet pathology per clinical assessment or radiology study that could explain the source of the pain. This is 
not met as records show that the enrollee has pain that radiates into his hips/thigh and soreness/tightness into his feet. His imaging shows spinal stenosis, and an electromyography shows radiculopathy findings associated 
with a nerve injury. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve lumbar spine medial branch block (MBB) (64493, 64494).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on January 3, 
2023. 
 
You asked the Plan to pay for the Cxbladder monitor test. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on January 3, 
2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) physical therapy (PT) visits (97110). 
 
 
 
 You asked the Plan to pre-approve the therapy services. You say that the additional PT is medically necessary. 
The Plan denied your request. The Plan says you started physical therapy on January 17, 2023, with complaints 
of low bone density and general deconditioning. At the start of care, range of motion was functional and lower 
extremity strength was 3/5. The clinical note does not indicate prior level of function or decline in function. 
The note from April 3, 2023, indicates you demonstrate compliance with the prescribed home program. The 
note does not show any new injuries, recent trauma or decline in function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twenty (20) physical therapy (PT) visits (97110).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 10, 2022, to 
September 8, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 12, 2022. The NOA was not received by the Plan until October 7, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 10, 2022, to September 8, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on January 28, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the medical records support the 
medical necessity for this service. The Plan denied your request. The Plan says that payment is not allowed for 
this service because it is not appropriate for the diagnosis billed. 
 
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 has not provided a coding rule or a code to substantiate the 
denial. Therefore, we decided that the Plan has to pay for an emergency department visit provided on  
January 28, 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.