Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 5, 2023, billed with 
codes 87801, 87798 and 87493. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this test was billed with payable codes. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 5, 2023, billed with codes 87801, 87798 and 87493.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab J0897). 
 You asked the Plan to pre-approve Prolia. You say that the enrollee has a history of osteoporosis and 
compression fracture. The Plan denied your request. The Plan says 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 Prolia. Our reviewer says that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of 
ibandronate, pamidronate or zoledronic acid before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the 
Plan's required drug(s) would likely be less effective or 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (denosumab J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient substance abuse detoxification. 
 
You asked the Plan to pre-approve inpatient substance abuse detoxification. You say that inpatient 
rehabilitation is necessary to treat your condition and save your life. The Plan denied your request. The Plan 
says the needed services can be provided safely in another setting such as residential, partial hospital program, 
or outpatient care. 
 
The Plan follows Medicare rules. Medicare rules state that inpatient substance abuse detoxification may be 
covered when 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 inpatient substance abuse detoxification. Our reviewer says that you do not meet criteria for inpatient level of care. Our physician 
reviewer found it does not appear medically necessary and reasonable to have psychiatric/detoxification care 
provided at the acute inpatient level of care rather than a lower level of care because you do not have any 
suicidal or homicidal thoughts, auditory or visual hallucinations, or abnormal behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient substance abuse detoxification have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient substance abuse detoxification.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) supplies 
from an out-of-network (OON) provider at the in-network benefit level. 
 
You asked the Plan to pre-approve CPAP supplies from an OON provider at the in-network benefit level. You 
say that the network vendors are 1 to 2 hours away from you. You say that you suffer from Vertigo and driving 
any distance makes you sick. You say that some of these episodes can last 10 days. The Plan denied your 
request. The Plan says there are participating providers available in your network who can provide the supplies 
needed. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide CPAP supplies. Under Medicare 
rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not 
have to pre-approve continuous positive airway pressure (CPAP) supplies from an out-of-network (OON) 
provider at the in-network benefit level.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 type of rehabilitation for the 
recuperation after their surgery. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for admission to an IRF. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall complies with the minimum documentation requirements for IRF admission. 
This enrollee's condition is in fact sufficiently complex and fragile, and there is every reason to expect that they 
will participate in and benefit from IRF-level services to include at minimum of physical and occupational 
therapy, physician oversight of wound care, polypharmacy, and case manager coordination of any additional 
services that might be needed to make a sustainable return home, as well as avoid preventable readmissions to 
the acute hospital. Therefore, the requested inpatient rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 ferumoxytol. 
  You asked the Plan to pre-approve ferumoxytol. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs. 
 
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 ferumoxytol. Our reviewer says that the 
enrollee has not tried and failed the Plan's preferred step one alternative. Our physician reviewer found the 
record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the 
preferred step one alternative. Therefore, the requested drug cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ferumoxytol.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Puraply XT, per square centimeter (Q4197). 
 
You asked the Plan to pre-approve wound care. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says that the records show a plan to use skin substitute 
on an acute wound following a procedure. The request is not medically necessary. 
 
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 wound care. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical documentation supports that an atypical dysplastic nevus was noted to the plantar 
aspect of the left fifth digit. Excision was recommended as the lesion was moderately atypical. This excisional 
site would encompass the whole plantar aspect of the fifth digit left side. The surgeon advises that this lesion 
would not be able to be closed primarily. They requested application of PuraPly XT postoperatively, which 
does appear reasonable. Medicare advises that they cover items or services that are reasonable or necessary for 
the treatment of an illness or injury or to improve the functioning of a malformed body member. These 
treatments must be safe and effective, not mainly for the convenience of the enrollee or the physician, 
appropriate in that it is furnished in accordance with accepted standards of medical practice for the diagnosis of 
the enrollee's condition, one that meets but does not exceed the enrollee's medical need, and at least as 
beneficial as existing and available medically appropriate alternatives. In this particular case, given the extent 
of the excision from the fifth digit, the enrollee's age, and the fact that this area is a weight-bearing area, the 
application of PuraPly XT does appear reasonable to facilitate healing and meets the above-mentioned 
guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care have been met. Therefore, we decided that the Plan has to pre-
approve Puraply XT, per square centimeter (Q4197).  
 
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 a power scooter (K0801). 
 
You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says your condition can be improved by a walker, cane or manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power scooter (K0801).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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. The Plan denied your 
request. The Plan says the enrollees medical condition does not require IRF services, and care can be provided 
in 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees condition is in fact complex and fragile. There is every reason to expect that the enrollee 
will participate in and benefit from services including physical therapy and occupational therapy. The enrollee 
will also benefit from physician oversight of their wound care and comorbidities, and case manager 
coordination of any additional services that might be needed to make their current home environment 
sustainable as well as avoid preventable admissions to the acute hospital. Therefore, the requested inpatient 
rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollee's needs can be managed at the current facility until they 
are more stable for transfer to another level of 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 the enrollee's care can be safely provided at the current facility until they are more 
stable and appropriate for transfer to another level of care. Completion of treatment at the current facility is 
recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee is stable for transfer to an 
LTACH. You also say the enrollee requires prolonged and intensive skilled nursing services that are not 
available at a lower level of care. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for an LTACH admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the acute hospital can provide for all the enrollees present inpatient care needs and 
the enrollee is receiving an appropriate level of care in the present setting. The provided records do not explain what care services will be provided in the LTACH that are not currently available. The records do not support 
the need to transfer from one acute hospital to another. Continued care in the short-term acute hospital is 
appropriate until the enrollee is stable to transfer to a lower level of care such as inpatient rehabilitation facility, 
a sub-acute rehabilitation facility, or a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 10, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 10, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218), provided on 
April 4,m 2023, through April 24, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pay for a fluid circulating cold pad with pump (E0218), provided on April 4,m 2023, through April 
24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the neck. 
 
You asked the Plan to pre-approve CT scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found her physician has ordered a CT of the neck 
with contrast to evaluate for enlarged lymph nodes. Based on eviCore Healthcare Clinical Guidelines, this CT 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the neck.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for approval of a ventilator. 
 
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 home ventilator. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the enrollee has been on trilogy since 
2018, and documentation states the unit is not functioning and the company that provided service has since 
gone out of business and can no longer service the device. The enrollee should not have change of a modality 
of therapy that has been of benefit, that would be substandard care. It is no fault of the enrollee that the device 
has failed, and provider of device is now not able to provide service, hence a functional device should be 
provided for best practice and care of 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 a home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
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.