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 will benefit from a more intensive immersive 
route to your recovery. The Plan denied your request. The Plan says that your ongoing skilled therapy and 
nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. 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 inpatient rehabilitation facility. 
Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you would like reconsideration because your leg 
are hurting and your health is declining due to the lack of approval for a chair lift. The Plan denied your 
request. The Plan says the chair lift is not medically necessary. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair glide.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic resonance (eg, proton) imaging, brain. 
 
You asked the Plan to pre-approve Magnetic resonance (eg, proton) imaging, brain. You say that the enrollee 
needs MRI brain imaging. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for an MRI of the brain. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 Magnetic resonance (eg, proton) 
imaging, brain. Our reviewer says that an MRI is not reasonable or medically necessary. Our physician 
reviewer found the medical records do not provide rationale for the MRI or prolactin level. The provider 
recommended repeating the prolactin level but records do not show that this was done. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Magnetic resonance (eg, proton) imaging, brain have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Magnetic resonance (eg, proton) imaging, brain.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Methylprednisolone (J1030) provided 
on November 2, 2020. 
 
You asked the Plan to waive the coinsurance for the Methylprednisolone. You say that the charge for the 
injection should be part of your $20 copay. The Plan denied your request. The Plan says your cost share was 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount for the Methylprednisolone is $6.09, 
and you are responsible for a 20% coinsurance, resulting in a total coinsurance amount of $1.22. 
 
You have been asked to pay 20% coinsurance for the Methylprednisolone. Methylprednisolone falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the Methylprednisolone (J1030) provided on November 2, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an Intracept procedure (22899, C9752). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
has not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found there is documented reasonable clinical evidence-based support for this specific 
procedure. In this case, the enrollee has chronic low back pain that has not responded to at least 6 months of 
reasonable conservative care. There are Type I and Type II Modic changes reflected on the lumbar spine MRI 
at the level of the requested procedure. Therefore, the requested Intracept procedure at L4-5 is 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 an Intracept procedure have been met. Therefore, we decided that the Plan has 
to pre-approve an Intracept procedure (22899, C9752).  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of osteoporosis. The documentation does not support that the enrollee has had a history of an osteoporosis-related fracture or that the enrollee has failed, or has a contraindication to zoledronic acid. There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug.

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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided 
from July 15, 2020, to September 16, 2020. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable. 
 
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, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9328 provided from July 15, 2020, to September 
16, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status currently does not require 
intensive physician and nursing supervision in an IRF. While you may benefit from additional physical and 
occupational therapy the documentation does not support that you require or can fully tolerate this therapy on 
an IRF level. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for CPAP supplies received on September 3, 2020. 
 
You asked the Plan to pay for the supplies. You say that you should not be charged for this. The Plan denied 
your request. The Plan says that there was no authorization on file. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The services were provided by the plan's contracted durable medical equipment provider. The file does not 
show that the Plan provided notice that the supplies would not be covered. Under Medicare rules, this means 
the supplies is considered approved by the Plan. Therefore, we decided that the Plan has to pay for CPAP 
supplies received on September 3, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120), bitewings - four 
radiographic images (X-Ray) (D0274), intraoral - periapical first X-Ray (D0220), intraoral - periapical each 
additional X-Ray (D0230) and prophylaxis - adult (D1110) provided on September 24, 2020. 
 
You asked the Plan to pay for periodic oral evaluation, bitewing X-ray, intraoral X-Rays and prophylaxis. You 
say that the services should be covered. The Plan denied your request. The Plan says your dental supplement 
benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, records indicate you exhausted your $1,000 annual 
maximum prior to these services and, therefore, the services are not covered. Therefore, we decided that the 
Plan does not have to pay for periodic oral evaluation (D0120), bitewings - four radiographic images (X-Ray) 
(D0274), intraoral - periapical first X-Ray (D0220), intraoral - periapical each additional X-Ray (D0230) and 
prophylaxis - adult (D1110) provided on September 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Reveal Line Monitor. 
 
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 the enrollee has palpitations concerning 
for a dysrhythmia. In this circumstance, if further evaluation for a dysrhythmia were thought to be medically 
necessary, the off-line monitoring devices such as Holter monitoring or extended external event monitoring 
would be the most appropriate initial evaluation. The records do not indicate the enrollee would not be able to 
manage these devices or that they have been previously placed. The requested services 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 a Reveal Line Monitor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee's lung sounds need to be assessed 
daily. The Plan denied your request. The Plan says care provided in excess of medical necessity is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and her 
lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, there is no 
documentation of skilled therapy being provided though one note mentions orders for occupational and speech 
therapy. The enrollee does not require skilled nursing or therapy on a daily basis. She does not meet severity of 
illness or intensity of service criteria for SNF stay. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you would like approval for these services to 
provided out-of-network. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 
physical therapy to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the denture. You say that you need the crowns done with your complete 
dental job to prevent the denture from falling. You say that you are having pain in your gums. You also say that 
sometimes your gums bleed when you brush your teeth. The Plan denied your request. The Plan says dentures 
are covered once every 5 year. The Plan says that the frequency limit for this item has been reached. The Plan 
also says that the enrollee's dentist did not provide reason of medical necessity to replace the existing denture 
within a 5 year period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 denture every 
5 years has been reached. The record shows that the Plan paid for a partial denture that you received on July 31, 
2017 less than 5 years ago. Therefore, we decided that the Plan does not have to pre-approve a complete lower 
denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on August 16, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says services 
rendered by non-participating providers require prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the durable medical equipment provided on August 16, 2020 by an out of 
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Variantyx custom four-gene testing panel. 
 
You asked the Plan to pre-approve the Variantyx panel. You say that this is absolutely medically necessary for 
this enrollee. You provide a detailed argument in support of the need for this testing and state that it will help 
with prognosis and determine which interventions are most appropriate. The Plan denied your request. The 
Plan says this testing will not likely have a meaningful clinical benefit since there are no disease-modifying 
treatments for Parkinsons disease. 
 
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 Variantyx panel. Our reviewer says 
that the requested genetic testing panel is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is diagnosed with Parkinson's disease, other symptoms and signs 
involving cognitive functions and awareness, REM sleep behavior disorder, and Dementia in other diseases 
classified elsewhere with behavioral disturbance. The enrollee also has diabetes, hypertension, kidney failure, 
and hyperlipidemia. The enrollee has cognitive decline and tremor. The cognitive profile is more suggestive of 
Alzheimer's disease, but the overall clinical picture is suggestive of early dementia with Lewy bodies. 
 
It has not been adequately demonstrated that Variantyx custom four-gene testing is reasonably expected to 
impact the enrollee's management and outcome. As such, the requested testing is not medically reasonable and 
necessary for the enrollee in this case and is not a covered Medicare benefit. 
 
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 Variantyx panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Variantyx custom four-gene testing panel.