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

We decided that the Plan does not have to pre-approve sedation for pain injections. 
 
You asked the Plan to pre-approve sedation. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neither conscious sedation nor Monitored Anesthesia 
Care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not 
routinely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the 
medical necessity of sedation is unequivocal and clearly documented. 
 
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 sedation. Our reviewer says that the 
requested sedation is not medically reasonable and necessary. Our physician reviewer found that according to 
the applicable LCD, neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary 
for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. The 
provided documentation does not support that conscious sedation is medically reasonable and necessary for this 
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 sedation have not been met. Therefore, we decided that the Plan does not have 
to pre-approve sedation for pain injections.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical cell stimulation treatment for the enrollee. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the exception to use an out-of-network provider, as the 
requested procedure is 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 treatment. Our reviewer says that 
the requested treatment is not considered medically reasonable and necessary in this case. Our physician 
reviewer found in short, there is a lack of high-quality literature that readily demonstrates that the use of this 
modality is beneficial in the management of low back/radicular pain. The few studies completed/published on 
this technology have been small (and thus underpowered). These studies have otherwise produced inconsistent 
clinical results. This type of therapy is not otherwise readily supported for use by current clinical practice 
guidelines. In this setting the proposed therapy would be otherwise considered to be experimental in nature and 
therefore not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve electrical cell stimulation treatment for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 87486, 87498, 87541, 87581, 87635, 87640, and 87798 provided on May 14, 2020.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 find that CPT codes 87486, 87498, 87541, 87581, 87635, 87640, and 87798 arenot supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. In addition, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service, 11.Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have topay forthe laboratory services coded 87486, 87498, 87541, 87581, 87635, 87640, and 87798 provided on May 14, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveDurysta.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has tried and failed treatment for glaucoma with maximal medical therapy using topical agents, and that the reason for failure was likely related to poor compliance. Additional treatment is medically necessary, and the treating physician and the enrollee opted for injectable Durysta, which has been shown in clinical trials to be a safe and effective treatment for his disease. The services are 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 these services have been met.Therefore, we decided that the Plan has to pre-approveDurysta.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The review has determined that the enrollee do not require services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. There are no services available at the 
LTACH that the enrollee 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 enrollee 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that the tooth that your previous partial denture 
broke after a year. You say that you are aware that the partial denture is only covered once every 5 plan years, 
however it should not break after only 1 year to begin with. You say that you should not have to pay for a new 
one because the partial was made with cheap materials. You also say that you were advised that the partial 
denture is not repairable. The Plan denied your request. The Plan says 1 partial lower denture is covered every 
5 plan years. The Plan says that the frequency limit has been reached. 
 
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 partial lower 
denture every 5 plan years has been reached. The record shows that the Plan paid for a partial lower denture 
that you received on August 2, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial 
lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions for teeth #19 and 31. 
 
You asked the Plan to pre-approve the extractions. You say that your jaw will deteriorate. The Plan denied your 
request. The Plan says the requested services are not covered. 
 
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.  
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested extractions are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental extractions for teeth #19 and 31.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF services.You asked the Plan to pre-approvethe SNF services. You say that you would like reconsideration because SNF care is needed in order for you to return home safely.The Plan denied your request. The Plan says you do not have any daily skilled needs which require the inpatient level of care.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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF services.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pre-approve emergency room services (99285) provided June 27, 2020. 
 
You asked the Plan to pre-approve the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the claim included an incorrect diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. No medical records were submitted to the IRE for review to determine if an 
appropriate diagnosis code was submitted. Therefore, we decided that the Plan has to pre-approve emergency 
room services (99285) provided June 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for preconception. 
 
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 testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, genetic testing for preconception, is being requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pre-approve genetic testing for preconception.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care from November 19, 2020, forward. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a 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 SNF care from November 19, 2020, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for upcoming cataract surgeries. 
 
You asked the Plan to waive the copayments for the cataract surgeries. You say that you cannot afford these 
surgical copayments. The Plan denied your request. The Plan says these copayments are a contractual 
obligation. 
 
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 $350 
copayment for outpatient procedures and services in an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $350 copayment for the cataract surgeries. the cataract surgeries fall within the 
outpatient procedures and services in an outpatient hospital or ambulatory surgical center 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 copayments for upcoming cataract surgeries.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office services to be provided at the in-network benefit 
level by an out-of-network cardiology specialist. 
 
You asked the Plan to pre-approve cardiology services. You say that this provider helped to treat your 
condition in the past, and you want to see him to get his opinions and treatment options. The Plan denied your 
request. The Plan says the denial of authorization at the in-network benefit level is correct, because this 
provider is out-of-network with the Plan and you can be treated by an in-network provider. The Plan also says 
that you may choose to see this provider using your out-of-network benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from either an in-network or out-of-network provider. 
Enrollees pay $35 copayment for each in-network specialist visit or 50% coinsurance for out-of-network 
specialist services. 
 
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 at the in-network benefit level. You may choose to see this 
provider using the Plan?s out-of-network benefits. Therefore, we decided that the Plan does not have to pre-
approve office services to be provided at the in-network benefit level by an out-of-network cardiology 
specialist.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on November 21, 2020, with a humeral head fracture. The most recent notes indicate that the member is able to 
ambulate with handheld assist with minimal assistance. She is non-weight bearing to the left upper extremity. 
She requires minimal assistance for transfers and bed mobility. She is able to ambulate up to 60 feet. She is 
medically stable with no skilled nursing needs. She has skilled therapy needs but does not require skilled 
therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair repair (K0739). 
 
You asked the Plan to pre-approve a shower chair repair. You say that a shower chair repair is medically 
necessary. The Plan denied your request. The Plan says a shower chair repair is a non-covered service under 
your contractual policy and by Medicare as a shower chair is a self-help device that is non-medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair repair may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
this service as a shower chair is not a covered benefit. Therefore, we decided that the Plan does not have to pre-
approve a shower chair repair (K0739).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve HFE gene analysis for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the results of this testing will not change the treatment of the enrollee's symptoms 
regardless of whether it is hereditary or not. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found HFE gene analysis as well as transferrin saturation testing was recommended to rule out 
hemochromatosis. Iron supplementation was recommended to be decreased to once daily. HFE gene testing 
and transferrin saturation are each standard of care for working up the diagnosis of hereditary hemochromatosis 
which is needed to coordinate and plan all future care for this patient, directly and indirectly. The gene testing 
will confirm the diagnosis and the patient has a strong indication for testing including a very high ferritin. 
Therefore, this enrollee meets criteria for this testing. 
 
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 testing have been met. Therefore, we decided that the Plan has to pre-
approve HFE gene analysis for the enrollee.  
 
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 pay for the retrobulbar injection rendered on June 8, 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 the claim was billed incorrectly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that procedure code 67500 was not billed with a 
required anatomical modifier. 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 pay for the retrobulbar 
injection rendered on June 8, 2020.