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

 
We decided that the Plan does not have to pay for vision services provided on August 28, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for vision services. You say that you were told that they were in-network. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that this provider is not 
in-network with the member's specific plan. 
 
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 has network providers 
available who can provide 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 vision services provided on August 28, 2020 by an 
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden (CPT Code 0037U) provided on 
June 23, 2020. 
 
You asked the Plan to pre-approve the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says they spoke with the provider's office and they did not find any records of any genetic 
tests being requested. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The provider's office did not 
request the genetic testing. Therefore, we decided that the Plan does not have to pre-approve targeted genomic 
sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene 
copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden (CPT 
Code 0037U) provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of foam sclerosant. 
 
You asked the Plan to pre-approve the injection of foam sclerosant. The Plan denied your request. The Plan 
says the enrollee must receive your care from a network provider. In most cases, care received from an out-of- 
network provider will not be covered.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve injection 
of foam sclerosant.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transcatheter insertion or replacement of a permanent leadless 
pacemaker (33274). 
 
You asked the Plan to pre-approve transcatheter insertion or replacement of a permanent leadless pacemaker. 
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 transcatheter insertion or replacement 
of a permanent leadless pacemaker. Our reviewer says that the requested items/services are considered 
medically reasonable and necessary in this case. Our physician reviewer found based on the records the 
enrollee has symptomatic bradycardia and is in need of pacemaker placement with no access via upper 
extremities due to venous occlusive disease. In this circumstance leadless pacemaker placement through leg 
veins is most appropriate. Furthermore the procedure is being performed as a part of an approved trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter insertion or replacement of a permanent leadless pacemaker have 
been met. Therefore, we decided that the Plan has to pre-approve transcatheter insertion or replacement of a 
permanent leadless pacemaker (33274).  
 
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 Durolane injections (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that the 
injections are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation to support that the Durolane is medically reasonable and necessary for the patient as 
there is no documentation that a diagnosis of osteoarthritis of the knee has been confirmed with imaging studies 
nor is there documentation that the enrollee has failed conservative treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane injections (J7318).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular 
physician evaluation.  The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic procedure and imaging studies for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no mention of any recent physical therapy. 
 
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 the enrollee presents with a history of chronic right knee pain. Pain increases with activities of daily 
living and disrupts sleep. He is non-ambulatory due to left above-the-knee amputation and utilizes a wheelchair 
and cane. Right knee exam findings are consistent with current radiographic evidence of Kellgren Lawrence 
grade 3 (moderate) osteoarthritis. He has failed to improve with NSAIDs and bracing. Prior physical therapy 
was reported to be of benefit 6 years ago. Under consideration is a request for Gelsyn injections, bracing, 10 
office visit, physical therapy, and arthrogram for a diagnosis of bilateral knee osteoarthritis and pain. In this 
case, the enrollee has only one remaining knee. Therefore, care to both knees is not medically reasonable and 
necessary. There is no indication provided to support the medical necessity of arthrogram, as the x-rays are not 
reported to be inconclusive and there are no findings of internal derangement on exam. There is no 
documentation of failed first line conservative treatment, including physical therapy and/or exercise and/or 
corticosteroid injection, to support hyaluronic acid injections at this time. The medical necessity of extended 
office visits is not supported by the medical records. Therefore, this request for orthopedic procedures and 
imaging is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an orthopedic procedure and imaging studies for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required, tooth 
#19 (CPT Code D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
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. This service is not listed in your dental handbook as a covered benefit; 
therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve core buildup, 
including any pins when required, tooth #19 (CPT Code D2950).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from June 10, 2020 
to July 10, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that that the enrollee was discharged 
from hospice on June 1, 2020 and admitted to the hospital. You say that the enrollee was admitted to the 
hospital again on June 10, 2020 until July 10, 2020. You also say that on July 10, 2020 the enrollee re-enrolled 
in hospice care on the same day. The Plan denied your request. The Plan says the Medicare hospice benefit, 
through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of 
discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit until June 1, 2020 and began again on July 10, 2020. The 
Medicare hospice benefit would cover all hospice care and physician services until the first day of the month 
following the month in which hospice was revoked or discharged. Additionally, since hospice was discontinued 
on June 30, 2020, coverage beginning with the Medicare Advantage plan would have started on July 1, 2020. 
 
 
Because the enrollment change occurred during the enrollee's inpatient stay, Original Medicare would be 
responsible for the inpatient stay from July 1, 2020 to July 9, 2020 as well.  Therefore, we decided that the Plan 
does not have to pay for the inpatient hospital services provided from June 10, 2020 to July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on June 9, 2020 and billed 
under codes 93320 and 93325. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We asked our physician reviewer to carefully 
review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the 
request to pay for this service. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found the records provided do not support the billing of codes 93320 and 93325. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
services provided to the enrollee on June 9, 2020 and billed under codes 93320 and 93325.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings were prescribed 
because you will be having surgery on your legs. The Plan denied your request. The Plan says Gradient 
Compression Stockings (A6534) are "non-covered under the surgical dressing benefit because they do not meet 
the statutory definition of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6534.
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. The Plan denied your request. The Plan says you are 
receiving appropriate inpatient acute care, and does not require transfer. 
 
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 physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include tracheostomy care, ventilator management, surveillance laboratory studies, tube feeding, 
and intense therapy services. The documentation does not support that the enrollee in this case requires services 
at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve the Euflexxa. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception 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 the Euflexxa. Our reviewer says that the 
Plan's step therapy criteria require trial of the preferred agent Monovisc. The documentation submitted does not 
support that the enrollee has tried and failed or cannot use Monovisc. Our physician reviewer found the 
prescriber does not state why the alternative required by the Plan would not be as effective for the enrollee as 
the requested drug or that it would have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Euflexxa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve the Xiidra. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's 
condition under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.  
 
Benefits for the Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. 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. Medicare rules say that PET 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 a PET CT scan from the skull base to 
mid-thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found this 
enrollee has had an aggressive condition with at least 2 recurrences despite chemotherapy and radiation 
therapy. While there has been complete remission via PET/CT by October 14, 2020, a follow-up PET/CT to 
document the continued success of the new chemotherapy agent in an enrollee prone to recurrence is 
reasonable and 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 a PET CT scan from the skull base to mid-thigh have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815).  
 
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.