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

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 You asked the Plan to pre-approve Gelsyn-3. You say that the enrollee has tried physical therapy at home, 
NSAIDS, bracing, topical ointments and steroid injections with no long-term relief of severe pain. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc or 
Supartz FX. 
 
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 Gelsyn-3. 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 not tried and failed the preferred drugs, Orthovisc or Supartz FX. The 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. Therefore, the reviewer found that 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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 pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you are on bilevel positive airway pressure 
(BIPAP) and does not provide substantial evidence for failure of BIPAP. You have normal pulmonary function 
tests (PFTs). You do not have arterial blood gas analysis (ABG) or hospitalization showing worsening 
hypercapnia. Hence, documentation does not support home ventilator per the documentation provided. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bavencio. 
 
You asked the Plan to pre-approve Bavencio. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested drug is not medically necessary  
 
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 Bavencio. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that Bavencio is not FDA-approved 
for the enrollees diagnosis. This use is not supported by one of the major compendia or by clinical research 
appearing in a Medicare-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 Bavencio have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Bavencio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter (OTC) COVID-19 test provided on July 
12, 2023. 
 You asked the Plan to pay for an OTC COVID-19 test. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that OTC COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that starting on May 12, 2023, OTC COVID-19 tests 
are no longer covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an over-the-counter (OTC) COVID-19 test provided on July 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided on February 19, 2021, to 
February 22, 2021. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the claim was accurately billed with the 
appropriate DRG. The Plan denied your request. The Plan says medical records and related documentation 
determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing 
policies. It is necessary in order to determine the amounts due to such provider. Due to not receiving any 
documentation within the timeframe the claim was denied. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. We find that the provider did not submit records for review, despite 
documented requests for the records by the Plan. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of inpatient hospital care 
have been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided 
on February 19, 2021, to February 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral brachioplasty (15836). 
 
You asked the Plan to pre-approve bilateral brachioplasty. You say that the enrollee has problems with the 
excess skin of the upper arms including recurrent rashes as well as recurrent injury. The Plan denied your 
request. The Plan says there is no evidence of functional problems due to this excessive skin. The Plan also 
says that this is cosmetic in nature and therefore is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 bilateral brachioplasty. Our reviewer 
says that the requested bilateral brachioplasty is not medically necessary. Our reviewer found the record 
indicates that the enrollee has excess sin and tissue in arms following weight loss due to bariatric surgery. The record provided does not establish that the requested service is for the prompt repair of accidental injury or to 
improve the functioning of a malformed body member. The record provided does not document the presence of 
chronic intertrigo refractory to conservative treatment. Therefore, the reviewer found that the requested 
bilateral brachioplasty 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 bilateral brachioplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral brachioplasty (15836).
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 enrollee needs this care to recover faster. The 
Plan denied your request. The Plan says medical records do not support the need for an IRF admission and, 
your needs can be provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not require 
IRF care with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be safely 
provided in an alternate 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 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: 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 would not be able to receive the proper care in 
home. The Plan denied your request. The Plan says the services you need can be provided safely in other 
settings.  
 
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. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: 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 enrollee needs the inpatient rehabilitation facility 
services to regain independance. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for inpatient rehabilitation facility services.  
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard intravenous immune globulin (IVIG). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that IVIG is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has acquired von 
Willebrands syndrome secondary to monoclonal gammopathy of unknown significance. The noted condition 
is not one that is either a Food and Drug Administration (FDA)-labeled indication or one which is an 
enumerated condition for which coverage is available. The Gammagard is not reasonable or medically 
necessary based on the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Gammagard intravenous immune globulin (IVIG).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Abraxane. 
 
You asked the Plan to pre-approve Abraxane. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 Abraxane. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the use is supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does 
support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Abraxane have been met. Therefore, we decided that the Plan has to pre-
approve Abraxane.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an ILR. 
 You asked the Plan to pre-approve the requested ILR procedure. You say that a new ILR is medically 
necessary. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found you have had atrial fibrillation repeatedly documented. There is no 
history of stroke or syncope. As such, based on current guidelines and the documentation provided, there is 
insufficient clinical evidence to support the medical appropriateness and necessity of replacing your old ILR 
with a new ILR. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an ILR.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the minimally invasive lumbar decompression (MILD) procedure 
(0275T). 
 
You asked the Plan to pre-approve the MILD procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says that there is no clinical documentation that supports that the enrollee is 
enrolled in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the MILD procedure. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain from spinal stenosis with neurogenic claudication. The 
enrollee has not responded to conservative therapy. The enrollees L4 to L5 stenosis is confirmed on imaging. 
The records do not demonstrate that the enrollee received a laminectomy, laminotomy, fusion, interspinous 
process decompression, or MILD procedure in the lumbar region during the last 12 months. The requested 
procedure meets the criteria for eventual admission into the required CED study. 
 
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 MILD procedure have been met. Therefore, we decided that the Plan has to 
pre-approve the minimally invasive lumbar decompression (MILD) procedure (0275T).  
 
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 Feraheme. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
He has not tried and failed the Plan's required drug, Venofer. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Feraheme is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 2, 2023, to May 30, 
2023. 
 You asked the Plan to pay for the home health services. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says the NOA was not received. 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 NOA was not received by the Plan. As a result, 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 May 2, 2023, 
to May 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 26, 2023, to July 2, 
2023. 
 
You asked the Plan to pay for the home health services. You say that this was a continuing claim, so you billed 
code 323. The Plan denied your request. The Plan says you billed this claim with the wrong Type of Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim). 
 In this case, you billed with Type of Bill code 323, when it should have been billed with code 329. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from June 26, 2023, to July 2, 2023.