Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neuropsychological testing. 
 
You asked the Plan to pre-approve Neuropsychological testing (96132, 96136, 96138). You say that you need 
Neuropsychological testing because your medical condition is progressing. The Plan denied your request. The 
Plan says Neuropsychological testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Neuropsychological testing (96132, 
96136, 96138). Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation is insufficient to demonstrate that 
Neuropsychological testing is medically reasonable and necessary for the enrollee in this case. Specific 
cognitive deficits have not been identified, and the case file does not contain results of the Brain Check and a 
detailed neurologic exam.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neuropsychological testing (96132, 96136, 96138) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Neuropsychological testing.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 8, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device 
(Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex procedure. You say that you have been waiting for this procedure 
for 2 years and cannot continue living with the pain. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this service is considered experimental/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 Vertiflex procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this spacer device is experimental, more research is needed to show its safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 24, 
2020. 
 
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 this claim should be submitted to Original Medicare. 
 
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 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise 
specified, contoured seating (K0108). 
 
You asked the Plan to pre-approve contoured seating. You say that please overturn the decision as the 
enrollee's current chair is not a backup and the enrollee is in need of a new chair asap. The Plan denied your 
request. The Plan says the captain's chair included with the approved wheelchair is all-inclusive. K0108 cannot 
be used for any component of a cushion. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of contoured seating have not been met. Therefore, we decided that the Plan does not have to pre-
approve wheelchair component or accessory, not otherwise specified, contoured seating (K0108).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee from December 
18, 2019, to December 26, 2019. 
 
You asked the Plan to pay for these services. You say that this claim should be covered by the Plan. The Plan 
denied your request. The Plan says this claim should be submitted to Original Medicare. 
 
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 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee from December 18, 2019, to December 26, 2019.
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 you had a craniotomy and needs rehab 
therapy. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care, and do 
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 you presented to the acute hospital with slurred speech and altered mental status. At the 
time of the request, your status is stable at the current level of care. You do not require services at the LTACH 
that are not available at the acute care hospital where you are currently receiving care. There are no services 
available at the LTACH that you require 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 long-term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device (E0652). 
 
You asked the Plan to provide a pneumatic compression device. You say that the basic pump caused additional 
truncal swelling. The Plan denied your request. The Plan says the enrollee has not received a sufficient trial of a 
basic pneumatic compression device and the required measurements are unavailable. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device 
(E0652).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sure injection. 
 
You asked the Plan to pre-approve Repatha Sure injection. You say that the medication is necessary. The Plan 
denied your request. The Plan says your plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Repatha Sure injection.  
 
Benefits for Repatha Sure injection 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee from July 6, 2020 
to July 26, 2020. 
 
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 Centers for Medicare & Medicaid Services (CMS) website, https://marx.cms.hhs.gov, shows 
the member was enrolled in hospice from December 04, 2019 through July 02, 2020 and August 29, 2020through August 
30, 2020. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper 
modifiers, for services rendered from July 06, 2020 through July 26, 2020.Per the regulations above, the member's claim 
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the 
member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member 
on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The services in question were provided before the end of that 
month. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee 
from July 6, 2020 to July 26, 2020..
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography (77065) provided on May 1, 
2020. 
 
You asked the Plan to pay for the diagnostic mammography. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that code 77065 was billed with one or more 
mismatched diagnosis codes. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying 
whether the condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left 
and right diagnosis codes when a more specific, in this case; a code for the right side is available. Therefore, we 
decided that the Plan does not have to pay for the diagnostic mammography (77065) provided on May 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you may not be able to complete your therapy sessions and reach your 
goals within a reasonable and predictable period of time. 
 
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 reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
 
 
 
 
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 skilled nursing facility (SNF) services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on July 21, 2020. 
 
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 this claim should be submitted to Original Medicare. 
 
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 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on July 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 outpatient physical therapy visits. 
 
You asked the Plan to pre-approve the PT visits. You say that you are requesting an appeal for physical 
therapy. The Plan denied your request. The Plan says the documentation does not support medical necessity for 
physical therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the therapy is not generally accepted as specific and effective therapy 
for the enrollees condition. The enrollee's high functional level does not require the unique skills of a 
professional therapist to safely and effectively provide treatment. The services do not need to only be 
performed only by or under a therapist to be safe and effective. The specialized skill, knowledge and judgment 
of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's 
current condition or to prevent or slow further deterioration. 
 
 
 
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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 outpatient physical therapy visits.
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
non-surgical management of a maxillary fracture after a fall. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation 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 IRF. 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide additional physical therapy. 
 
You asked the Plan to provide 8 additional therapeutic procedures (97110) and US therapy modality (97035). 
You say that the enrollee needs additional physical therapy. The Plan denied your request. The Plan says the 
records do not show the enrollee has made progress. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 provide 8 additional therapeutic procedures (97110) 
and US therapy modality (97035). Our reviewer says that skilled services are not necessary to restore or 
maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on 
the medical records provided there is no documentation that the requested therapy is generally accepted as 
specific and effective therapy for the enrollee's condition. Based on the available records the enrollee appears 
to have plateaued with therapy. Further therapy at this point does not appear to be likely to achieve any 
significant improvement in the enrollee's symptoms or functional status. Based on the medical records provided 
there is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required 
to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration. Further therapy at this point does not appear to be likely to achieve any significant 
improvement in the enrollee's symptoms or functional status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional therapeutic procedures (97110) and US therapy modality (97035) 
have not been met. Therefore, we decided that the Plan does not have to provide additional physical therapy.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve the Remicade. You say that you would like to switch Enbrel to Remicade 
due to a lack of clinical improvement. The Plan denied your request. The Plan says the enrollee does not have a 
history of failure, contraindication, adverse event, or intolerance to the formulary alternatives. The Plan says 
that there is no reason given on why the enrollee is unable to try Inflectra or RENFLEXIS. 
 
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 Remicade. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of 
psoriatic arthritis. The case file does not contain documentation of a trail and failure with Inflectra or 
RENFLEXIS. There is no documentation that Inflectra or RENFLEXIS would likely be less effective, and/or 
would likely have adverse effects for the enrollee in this case. 
 
 
 
 
 
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 Remicade have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Remicade.