Persius/hicric huggingface dataset:
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 need IRF services as you want to return home 
and live independently as before your hospitalization. The Plan denied your request. The Plan says you do not 
meet the requirements for an IRF admission.  
 
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. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement. However, the documentation does not support that you would meet 
criteria for admission to an IRF. You 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 nerve stimulator. 
 
You asked the Plan to pre-approve nerve stimulator. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says it is not a covered benefit by Medicare. 
 
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 nerve stimulator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided medical records and review of the current peer-reviewed medical literature do not 
document that use of the nerve stimulator has been shown in controlled studies in a Medicare-approved journal 
to result in sustained long term health benefits in patients with meralgia paresthetica, fibromyalgia, and 
migraine headaches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve stimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve nerve stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient level of care admission for a hernia repair 
(49591). 
 
You asked the Plan to pre-approve the inpatient level of care. You say that your previous hernia surgery was 
complicated. You say that you were in the hospital for seven days. You also say that you feel the observation 
would not be long enough. The Plan denied your request. The Plan says the inpatient level of care is not 
medically necessary. 
 
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 pre-approve the inpatient level of care. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found there was no documentation provided indicating inpatient level of care services for 
the elective procedure. The procedure is not on the Inpatient Only List. The enrollee was medically cleared for 
the procedure. Therefore, the reviewer found that the request for the inpatient level of care is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient level of care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient level of care admission for a hernia repair (49591).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our reviewer says that 
the criteria for coverage of Eylea have not been met. Our physician reviewer found that the Plan requires a trial 
of Byooviz before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the Plan's required drug would likely be less 
effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a compounded drug (J7999) provided on July 6, 2023. 
 
You asked the Plan to pay for a compounded drug (J7999). You say that the claim was processed incorrectly. 
The Plan denied your request. The Plan says that the invoice was incomplete or invalid. 
 
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. We find that the Plan says this procedure code is incidental to a primary 
procedure and the invoice is incomplete or invalid. The Plan has not submitted documentation that the code in 
dispute is incidental to another primary procedure that has already been adjudicated. The Plan has also not 
supported that the invoice is incomplete or invalid. It is the burden of the Plan to substantiate their denial with 
evidence. The denials have not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for a compounded drug (J7999) provided on July 6, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on April 25, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article (LCA) A58720, this type of testing must be billed with a single unit of service of a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 23, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed lab services is not supported in the medical record. Specifically, the 
Clinical Laboratory Improvement Amendments (CLIA) number provided in the medical records does not 
match the CLIA provided on the claim form. 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 23, 2023.
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 a total electric hospital bed. You say that given the enrollee's short stature, 
weakness, frequent falls, pressure ulcer, and recent fall with Subdural Hematoma requiring hospitalization, he 
is in great need of fully adjustable bed to prevent all of the above. The Plan denied your request. The Plan says 
this item is 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of LinQ sacroiliac (SI) joint stabilization 
system (0775T). 
 
You asked the Plan to pre-approve LinQ SI joint stabilization system. You say that this is safe and effective. 
The Plan denied your request. The Plan says this is experimental and therefore is not covered. 
 
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 LinQ SI joint stabilization system. Our 
reviewer says that the requested LinQ SI joint stabilization system is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental/ investigational 
device. Therefore, the reviewer found that the requested LinQ SI joint stabilization system is 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 LinQ SI joint stabilization system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the placement of LinQ sacroiliac (SI) joint stabilization system 
(0775T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chemodenervation of one extremity (64642), 
chemodenervation of each additional extremity (64643) and 600 units of Botox (J0585) every 3 months for one 
year. 
 
  You asked the Plan to pre-approve the chemodenervation of one extremity (64642), chemodenervation of each 
additional extremity (64643) and 600 units of Botox (J0585). You say that the requested increase in dosage is 
to help the enrollee with muscle stiffness in their left leg and shoulder. The Plan denied your request. The Plan 
says that the request exceeds the suggested dosage. 
 
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 chemodenervation of one extremity 
(64642), chemodenervation of each additional extremity (64643) and 600 units of Botox (J0585). Our reviewer 
says that the chemodenervation of one extremity (64642), chemodenervation of each additional extremity 
(64643) and 600 units of Botox (J0585) is not medically necessary. Our physician reviewer found that there is 
no support that the chemodenervation of one extremity (64642), chemodenervation of each additional 
extremity (64643) and 600 units of Botox (J0585) every 3 months for one year meet all Medicare criteria for 
medically reasonable and necessary safe and effective for the enrollee. The major drug compendia and LCD do 
not support a dose of Botox more than 400 units every 12 weeks for the enrollee's diagnosis. Therefore, the 
Botox at this dosage does not meet the criteria for coverage and the associated procedures are not covered. 
 
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 chemodenervation of one extremity (64642), chemodenervation of each 
additional extremity (64643) and 600 units of Botox (J0585) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the chemodenervation of one extremity (64642), chemodenervation of each 
additional extremity (64643) and 600 units of Botox (J0585) every 3 months for one year.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 You asked the Plan to pre-approve Udenyca. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, FulphilaTM 
(pegfilgrastim-jmdb) or Neulasta (pegfilgrastim). 
 
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 Udenyca. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer also found that there is no 
indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the requested drug, Udencya, is not medically reasonable or 
necessary as the step therapy criteria have not been 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 Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Privigen.  
 
You asked the Plan to pay for Privigen. You say that you feel this should be covered because this disease can 
affect any of your senses, as well as paralyzing you. The Plan denied your request. The Plan says the requested 
drug is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare may cover the use of an FDA-approved 
drug or biological if it is safe and effective and otherwise reasonable and necessary for the patient. FDA 
approved drugs used for indications other than what is indicated on the official label may be covered if the use 
is determined to be medically accepted, taking into consideration the major drug compendia, authoritative 
medical literature and/or accepted standards of medical practice. 
 
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 Privigen. Our reviewer says that you do not 
meet criteria for the use of Privigen. Our physician reviewer found the requested use of Privigen is not FDA-
approved for your diagnosis. The use of Privigen is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have 
to pay for Privigen.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl (luspatercept-aamt) J0896). 
 
You asked the Plan to pre-approve Reblozyl. You say that please reconsider coverage of this drug. The Plan 
denied your request. The Plan says the requested treatment is not considered medically necessary for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 pre-approve Reblozyl. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Luspatercept-aamt (REBLOZYL, Celgene Corporation) is FDA (Food and Drug 
Administration) approved for the treatment of anemia failing an erythropoiesis stimulating agent and requiring 
2 or more red blood cell (RBC) units over 8 weeks in adult patients with very low- to intermediate-risk 
myelodysplastic syndromes with ring sideroblasts (MDS-RS) or with\ myelodysplastic/myeloproliferative 
neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T). In this case there is no documentation 
of ring sideroblasts. The review has determined that the documentation does not support that the Reblozyl is 
medically reasonable and necessary for the enrollee and does not support that the Reblozyl is safe and effective 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl (luspatercept-aamt) J0896).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. 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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary bike.  
 
You asked the Plan to pre-approve a stationary bike. You say that you are a diabetic who uses insulin, and you 
cannot go outside to do exercises. You said that your doctor recommended this equipment. The Plan denied 
your request. The Plan says exercise equipment is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that exercise equipment is not covered 
because it is not primarily medical in nature.  
 
While a stationary bike may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a stationary bike.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an LTACH care. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.