Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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. Our 
physician reviewer found the health plan's denial should be upheld. You do not require the intensity of services 
provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week 
of rehabilitative services with regular physician evaluation. Your 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the ophthalmology services. You say that you would like reconsideration because your condition has not been properly assessed in over a year. The Plan denied your request. The Plan says the services you require are readily available and accessible within the 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 the medical services to be provided by an out of network (OON) provider.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted to the current acute care hospital with COVID-19 pneumonia. The course was 
complicated by superimposed bacterial pneumonia, NSTEMI, hyponatremia, and fluid overload. He was 
treated with antibiotics, steroids, remdesivir, convalescent plasma, oxygen supplementation, fluid management, 
and other supportive measures. He is still requiring high oxygen supplementation and has a guarded prognosis 
but is gradually improving, according to recent notes. 
 
The enrollee in this case appears to be still requiring acute care services due to oxygen requirements. It does 
not appear, however, that he is likely to require acute care services for more than 24 days. The enrollee does 
not require any services at the LTACH that are not already available at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Therefore, this request for LTACH services will be considered not 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 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 Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that Gel-one is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has 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 Gel-One. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental 
treatments DUROLANE, EUFLEXXA, or GELSYN-3. Step therapy, as outlined by the plan, requires these be 
trialed first. The documentation does not outline contraindications or reasons these medications were not 
considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
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 the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 patient does not require complex medical management services at the LTACH 
that are not available at the acute care hospital where the enrollee is currently receiving care. There are no 
services available at the LTACH that the patient requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the patient and able to be furnished safely and effectively only on 
an inpatient basis. 
 
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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee should be referred for physician-directed home exercise program or 
formal physical therapy. 
 
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 the injections. Our reviewer says that 
the requested injections are not medically reasonable or necessary. Our physician reviewer found there is no 
examination of the enrollee's knee. There is no documentation of a failure to/intolerance of analgesic 
medication. There is no failure of a formal physical therapy program has been documented. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81201, 81408, 81406, 
81242, 81288, 81295, 81298, 81317, 81298, 81317, 81259, 81325 and 81162 provided July 11, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records have attached are what 
was supplied to you from the ordering physician along with the copy of the requisition and your lab results for 
the lab work performed by your lab. The Plan denied your request. The Plan says the records do not support the 
billed service, the records does not contain a valid physician order/lab requisition, or relevant medical records, 
there is no evidence of an established relationship between the enrollee and the ordering physician, there was 
no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth 
service with the ordering physician as required per CMS guidelines and genetic hereditary predictive screening 
testing is not a Medicare benefit for the diagnosis listed and are done for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded as 81201, 81408, 81406, 81242, 81288, 81295, 81298, 81317, 81298, 81317, 81259, 81325 and 81162 
provided July 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit (J0885). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Retacrit, for two consecutive months with appropriate dose adjustment. 
 
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 Procrit (J0885). Our reviewer says that 
the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical records 
provided the enrollee has not tried and failed the required drug and there is no indication that the plan's required 
drug would likely be less effective and/or likely 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 Procrit (J0885) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Procrit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EUFLEXXA for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says if you meet the clinical criteria, you must meet the step therapy requirements. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered. Without the support of the documentation, EUFLEXXA is not approved as 
step criteria is not 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve EUFLEXXA for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on February 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on February 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thromboendarterectomy services coded 35371 provided 
on January 30, 2020. 
 
 
You asked the Plan to pay for the thromboendarterectomy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 35371 is thromboendarterectomy, including patch graft, 
if performed; common femoral. 
 
We find that CPT code 35371 is not supported in the medical record. Specifically, this code was not billed with 
an anatomical modifier (LT, RT, 50) to specify the location of the procedure. Based on this information, we 
decided that Medicare rules for coverage of the thromboendarterectomy services have not been met. Therefore, 
we decided that the Plan does not have to pay for the thromboendarterectomy services coded 35371 provided 
on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility assessment provided on October 23, 2018.
You asked the Plan to pay for the nursing facility assessment (99318). You say that this is a corrected claim. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the nursing facility assessment (99318) was not filed until April 29, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the nursing facility assessment provided on October 23, 2018.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency care services provided on June 9, 2019. 
 
You asked the Plan to pay for emergency care. You say that you are requesting payment for these services. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because payment 
for these services has been made by the primary insurance carrier for this claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. If the primary payer does not pay in full for the services, 
Medicare secondary benefits may be paid. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that your primary insurance carrier has fully paid for this claim. Therefore, there is no remaining amount of this 
claim that would be the Plan?s responsibility to pay. Therefore, we decided that the Plan does not have to pay 
for emergency care services provided on June 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a foot insert (L3000) provided on November 26, 2019. 
 
You asked the Plan to pay for a foot insert. You say that this was medically necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for a foot insert 
(L3000) provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #7 and retainer crowns 
(D6750) for tooth #'s 6 and 8. 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that the only recommended 
treatment is either a bridge or an implant. You also say that a denture or partial is not recommended for a one 
tooth replacement. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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. The Plan covers the pontic and 
retainer crowns when the services are medically necessary and reasonable.  
 
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 pontic and retainer crowns. Our 
reviewer says that the bridge does not meet the Plan's coverage criteria. Our physician reviewer found there has 
been no showing of a physical or neurological disorder in the supplied record.  Our reviewer found that 
although a fixed bridge is an optional treatment plan in this case, it is not medically necessary as a removable 
appliance can be reasonably fabricated and worn.  Our physician reviewer also found that given the Plan 
criteria, there is no finding of medical necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pontic (D6240) for tooth #7 and retainer crowns (D6750) for tooth #'s 6 
and 8.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete blood count (CBC) and transferrin testing 
provided on February 4, 2020. 
 
You asked the Plan to pay for the CBC and transferrin testing. You say that this testing should be covered. The 
Plan denied your request. The Plan says the order did not specify the testing requested. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a 
treating provider. 
 
The order form indicated a panel but did not specify what testing was included in the panel. Without an order 
for this specific testing, coverage rules have not been met. Therefore, we decided that the Plan does not have to 
pay for the complete blood count (CBC) and transferrin testing provided on February 4, 2020.