Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided image guided radiation therapy 
(IGRT). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found using ultrasound for IGRT is approved 
by the Food and Drug Administration (FDA); however, daily imaging for a technology for which need has not 
been established is not supported by published data or supported by consensus guidelines. The services are not 
the standard of care and are not reasonable or medically necessary at this time.  
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 ultrasound-guided image guided radiation therapy (IGRT).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimerli. 
 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 not tried and failed the 
Plan's required drug, bevacizumab. The records do not show that the required drug would be contraindicated or 
less effective; therefore, Cimerli is not reasonable or 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 Cimerli.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty. 
 
You asked the Plan to pre-approve blepharoplasty. You say that it is medically necessary. The Plan denied your 
request. The Plan says it is not medically necessary for your loose eye skin. 
 
The Plan follows Medicare rules. Medicare rules say that any procedure(s) involving blepharoplasty must be 
supported by documented which justify functional surgery. The documentation must address the signs and 
symptoms commonly found in association with ptosis, pseudoptosis; blepharochalasis and/or dermatochalasis. 
 
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 blepharoplasty. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the clinical notes did not document any 
details of symptoms affect functional activities of daily living. The visual fields did not show any super visual 
field defect for either right or left eyelids. the color photo did not show significant upper eyelid skin resting on 
eyelashes nor over eyelid margin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of blepharoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve blepharoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid treatment services provided on April 26, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider cannot 
bill for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that only an entity enrolled with Medicare as an OTP 
can bill OTP services. 
 
We looked at the file and Medicare rules. The provider in this case is not enrolled with Medicare as and OTP 
and therefore cannot bill for the requested services. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
opioid treatment services provided on April 26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on July 11, 2023, by an 
OON provider.  
 You asked the Plan to pay for the nursing facility care. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. The services could have been provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on July 11, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that denying this treatment may possibly deny your 
life-saving treatment. The Plan denied your request. The Plan says this requested service is out-of-network and 
it could be performed in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and psychotherapy service provided on 
January 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the enrollee provided the incorrect insurance 
information. You also say that this was medically necessary for the enrollee. The Plan denied your request. The 
Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
You are not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found 
no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan 
does not have to pay for the office visit and psychotherapy service provided on January 2, 2023, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that hyperbaric oxygen therapy is 
medically necessary. The Plan denied your request. The Plan says hyperbaric oxygen therapy is not medically 
necessary because the records show that the enrollee does not have measurements documenting 30 days of no 
measurable signs of healing with standard wound therapy for a diabetic ulcer, or to document osteomyelitis is 
refractory to standard medical and surgical management. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered when the 
criteria listed in the Medicare rules section of this decision 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 hyperbaric oxygen therapy. Our 
reviewer says that the requested hyperbaric oxygen therapy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this patient has a diabetic foot ulcer with osteomyelitis.  
The patient was hospitalized February 16, 2023 for a right foot wound with osteomyelitis. On  
February 23, 2023, the patient underwent incision and drainage and fifth ray amputation. It appears the patient 
left the hospital against medical advice on February 23, 2023 or February 24, 2023. The patient was seen in 
follow-up on July 20, 2023. The size of the wound was documented after debridement as 8.5 x 2.4 x 3.3 cm.  
There is no previous documentation of wound size. The Medicare requirement of failure of standard therapy, 
with no measurable signs of healing for at least 30 consecutive days of standard wound care has 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 hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
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 like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF services do not meet the 
requirements for approval.  
 
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 the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy 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 the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the wound has been present for greater 
than 30 days without improvement. The Plan denied your request. The Plan says there is no documentation of 
surgical debridement.  The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under 
certain medical indications. 
 
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 services. Our physician 
reviewer found that the enrollee has a diagnosis of a diabetic foot ulcer. There is no documentation that the 
requested therapy is indicated for the enrollee's condition. The provided records in this case do not document 
"maintenance of a clean, moist bed of granulation tissue" as required. After the latest debridement on October 
9, 2023, the records continue to document the wound bed is covered with non-viable tissue. There is no 
documentation that the requested therapy meets all Medicare criteria for medically reasonable and necessary 
and 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic testing for the APOE gene (81401). 
 
You asked the Plan to pay for APOE gene testing. You say that you have a family history of Alzheimer's 
disease. The Plan denied your request. The Plan says this testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the APOE gene is unlikely to impact 
therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care of the 
beneficiary and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of molecular genetic testing for the APOE gene have not been met. Therefore, we decided that the 
Plan does not have to pay for molecular genetic testing for the APOE gene (81401).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 19, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that j96.20 has an Excludes1 note in relation to R09.02. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on April 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need admission to a skilled nursing facility and 
rehabilitation to gain strength back again. The Plan denied your request. The Plan says you have no skilled 
nursing needs. The Plan says needs are custodial. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve brachytherapy. 
 
You asked the Plan to pre-approve brachytherapy. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that it 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 brachytherapy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found hormonal therapy was discontinued due to toxicity and the enrollee was offered local therapy to 
the position emission tomography (PET) avoid, pathologically confirmed recurrence. Brachytherapy remains a 
standard of care options for locally recurrent prostate cancer after prior external beam radiation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of brachytherapy have been met. Therefore, we decided that the Plan has to pre-
approve brachytherapy.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the services. You say that if therapy is not approved, the margin size will 
increase substantially, which would result in a higher kidney dose. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it seems as though IGRT is simply being used as routine practice, as there does not seem to be any 
exceptional circumstances with this patient necessitating the need for IGRT and the records do not sufficiently 
justify the need for IGRT.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered experimental/ investigational therapy. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular artery embolization.
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 Eylea. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the step therapy requirements for the requested 
drug to be approved. 
 
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 Eylea. Our reviewer says that the 
requested drug does not meet the step-therapy criteria necessary for approval. Our physician reviewer found the 
requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed 
the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to 
or would have an adverse effect from the plan's preferred step one alternative. The requested service cannot be 
recommended as the elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.