Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thirty (30) additional home health care skilled nurse 
visits. 
 
You asked the Plan to pre-approve the services. You say that you need the nurse to continue coming out daily 
for wound care to prevent infection. The Plan denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 physician reviewer 
found based on the documentation provided, the health plan?s denial should be upheld. You are not shown to 
require home registered nurse (RN) services at the frequency requested. You have an isolated wound and 
caregivers who are able to help with dressing care. You can received less frequent home RN visits. 
 
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 thirty (30) additional home health care skilled nurse visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for Pilates training provided from October 17, 2019, 
through December 19, 2019. 
 
You asked the Plan to reimburse you for the Pilates training. The Plan denied your request. The Plan says your 
Plan has a Fitness Program coverage through the Plan's fitness provider, which is a health and fitness program 
that provides monthly basic memberships. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
only when provided by the Plan's fitness provider. 
 
The Plan's rules for coverage of gym benefits have not been met because the provider at issue in this case is not 
a contracted Plan fitness provider. Therefore, we decided that the Plan does not have to reimburse you for 
Pilates training provided from  October 17, 2019, through December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown and core buildup for tooth #30. 
 
You asked the Plan to pre-approve the crown and core buildup. You say that tooth #30 has a large existing 
filling with distal decay and severe wear. You say that there are visible fracture lines and the enrollee is having 
sensitivity. The Plan denied your request. The Plan says the tooth may be restored by lesser means. 
 
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 crown and 
core buildup 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 crown and core buildup. Our 
reviewer says that the crown and core buildup are not medically necessary. Our physician reviewer found an 
existing two surface restoration with only some recurrent decay. Our reviewer says that there is no extensive 
decay that would compromise the integrity of any cusps or cause an excessive loss of structure such that a 
crown would be needed. Our reviewer says that it would not be reasonable to place a core buildup and crown 
restoration on tooth #30. 
 
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 crown and core buildup have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the crown and core buildup for tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that claims for ventilators used to provide CPAP or bi-
level CPAP therapy for conditions described in this RAD policy will be denied as not 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 a home ventilator. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found there was no documentation or 
physician statement justifying use of the mechanical ventilator vs the BiPAP unit use. Therefore, this request 
for the home ventilator (E0466) 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee continues to have radicular symptoms. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain, and failed back surgery syndrome. He had 2 level 
lumbar hemilaminectomies. His EMG shows 3 levels of motor radiculopathy and multi-level degenerative disc 
disease as well as a disc protrusion. The imaging also shows foraminal stenosis. The enrollee does not meet the 
coverage criteria because he has documented radiculopathy. Therefore, the request is not medically reasonable 
or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator. 
 
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 history of failed conservative treatments in the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that conservative treatments must have failed for a 
neurostimulator to be covered.  
 
There is no evidence that this treatment is being requested as a last resort. The file shows that medications gave 
a 50% improvement. Conservative treatment has not been failed. 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 a neurostimulator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve 11 additional physical therapy visits. You say that the enrollee reports 
notable improvement in function and decreased pain when participating in physical therapy. You say that you 
recommend continued therapy to minimize pain. The Plan denied your request. The Plan says additional visits 
are not medically necessary. 
 
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 11 additional physical therapy 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 that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing 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 11 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent 75mg/mL injector pens. 
 
You asked the Plan to pre-approve the Praluent pens. You say that the enrollee has had a stent placed and 
cannot tolerate statins. The Plan denied your request. The Plan says this self-injected drug is not covered by 
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 Praluent 75mg/mL injector 
pens.  
 
Benefits for the Praluent pens 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 17. 
 
You asked the Plan to pre-approve the dental service. You say that you need a crown for tooth # 17. You say 
that you need to save this tooth. You also say that tooth # 17 will be used as an anchor tooth for your bridge. 
The Plan denied your request. The Plan says the tooth does not appear to have significant breakdown. The Plan 
also says that the crown for tooth # 17 is not medically necessary at the time. 
 
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 dental 
service 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 dental service. Our reviewer says 
that the requested crown for tooth # 17 does not meet the criteria for coverage. Our physician reviewer found 
there is minimal missing or damaged structure associated with tooth #17. The reviewer found there would be 
no clear indication for a full coverage crown in this instance. Therefore, the reviewer found that the Plan 
criteria has not been met. 
 
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 dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2750) for tooth # 17.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network 
provider. 
 
You asked the Plan to pre-approve the physical therapy. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the 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 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 and who are accessible. 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 physical therapy to be provided by the out-of-network 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 enrollee would benefit from LTACH 
care. The Plan denied your request. The Plan says due to the recent emergency intubation, transfer to another 
facility is not reasonable at this time. 
 
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 is a 65 year old female who was admitted to the current acute care hospital 
with COVID-19 pneumonia and acute hypoxic respiratory failure. She was treated with antibiotics, steroids, 
Lasix, remdesivir, breathing treatments, BiPAP, and high flow oxygen. Recent notes show her breathing status 
had been improving, but turned worse, requiring intubation. 
 
The patient appears to be worsening which requires additional short term acute care services, which can be 
safely completed at the current facility until stable. The patient does not require services at the LTACH that are 
not already available at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer may be considered when treatment has completed and she is stable. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (CPT 99354, CPT 99355) provided from May 19, 2020, to 
May 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed services 
do not follow the coding guidelines. 
 
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 99354 is "Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service 
time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond 
the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and 
Management or psychotherapy service)." The CPT Code Manual Definition of code 99355 is "Prolonged 
evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary 
procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; 
each additional 30 minutes (List separately in addition to code for prolonged service)." 
 
We asked our coding 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 the services. Our reviewer says that the use 
of CPT codes 99354 and 99355 is supported by the records provided. Our coding reviewer found that the 
provider documented their presence in the enrollee's room during administration of SPRAVATO. Per 
SPRAVATO safety guidelines, "SPRAVATO is intended for patient administration under the direct 
observation of a healthcare provider, and patients are required to be monitored by a healthcare provider for at 
least 2 hours. SPRAVATO must never be dispensed directly to a patient for home use." A physician is a 
healthcare provider and would determine the level of service required for administration of this medication, and 
to ensure the safety of the patient. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the services (CPT 99354, CPT 99355) provided from May 19, 2020, to May 26, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trans-catheter mitral valve repair, percutaneous approach, 
including trans-septal puncture when performed; additional prosthesis(es) during same session (33419) 
provided May 6, 2020. 
 
You asked the Plan to pay for trans-catheter mitral valve repair. You say that you are resubmitting the claim 
with additional supporting documents to support the service. The Plan denied your request. The Plan says the 
procedure code billed is missing a required modifier. 
 
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 33419 is trans-catheter mitral valve repair, percutaneous 
approach, including trans-septal puncture when performed; additional prosthesis(es) during same session. (List 
separately in addition to code for primary procedure.)  
 
We find that CPT code 33419 is not supported in the medical record. Specifically, Medicare criteria says that 
percutaneous trans-catheter mitral valve repair procedures are only covered when reported with a modifier 
indicating participation in an approved clinical trial. Procedure 33419 was not reported with a required 
modifier. A corrected claim must be submitted. Based on this information, we decided that Medicare rules for 
coverage of trans-catheter mitral valve repair have not been met. Therefore, we decided that the Plan does not 
have to pay for trans-catheter mitral valve repair, percutaneous approach, including trans-septal puncture when 
performed; additional prosthesis(es) during same session (33419) provided May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve the BRCA testing. You say that it is felt this testing should be allowed. The 
Plan denied your request. The Plan says the enrollee does not meet the CMS guidelines for coverage of BRCA 
testing. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA testing may be considered reasonable and 
necessary for enrollees who meet the above criteria.  
 
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 BRCA testing. Our reviewer says 
that the requested testing is not considered reasonable and necessary in this particular case according to 
Medicare rules. Our physician reviewer found the patient is a 73-year-old female with a medical history of 
metastatic colon cancer with metastases to the liver. A request for BRCA testing was made. The Medicare 
criteria for BRCA testing states that it is not justified if the patient does not have at least a personal history of 
breast, ovarian, peritoneal, prostate, or pancreatic cancer. This patient has a history of colon cancer with 
metastases to the liver, but no other personal history of cancer. She does not have a covered indication for the 
requested genetic 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 BRCA testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve BRCA genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent compression device (E0676) and a 
gastric band (S2083). 
 
You asked the Plan to pre-approve an intermittent compression device and a gastric band. You say that you 
need these items to have surgery. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD that provides intermittent limb 
compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items 
that are used for a preventative service or function are excluded from coverage under the Medicare DME 
benefit. The rules also say that status code "I = Not valid for Medicare purposes."
 
We looked at the file and Medicare rules. The requested compression device is preventative and is not covered. 
The gastric band was requested with code S2083, which has a status code of I and is not valid for Medicare. 
Based on this information, we decided that Medicare rules for coverage of an intermittent compression device 
and a gastric band have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
intermittent compression device (E0676) and a gastric band (S2083).