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

We decided that the Plan does not have to pre-approve Gelsyn (J7328). 
 
You asked the Plan to pre-approve the Gelsyn. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the information submitted does not meet the 
Plan's medical necessity criteria for coverage. 
 
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 Gelsyn. Our reviewer says that there 
is no indication that the member has tried and failed the required step therapy drugs, Orthovisc and Monovisc. 
Our physician reviewer found there is no indication in the submitted medical records that the Plan's required 
drugs are likely to be less effective or have adverse effects. 
 
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 Gelsyn have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gelsyn (J7328).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of 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. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from November 19, 2020, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on June 17, 2020. 
 
You asked the Plan to pay for Guardant360 testing. You say that this testing was deemed medically necessary 
and the enrollee did not have an in-network provider option. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service June 17, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, 
we decided that the Plan does not have to pay for Guardant360 testing provided on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on June 6, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that the foot orthotics are 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on June 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of CPAP device (CPT Code E0601). 
 
You asked the Plan to pre-approve the CPAP device. You say that the services are necessary. The Plan denied 
your request. The Plan says the information shows that you used the device at least four (4) hours/night only 
32.2% of the time and this does not meet Medicare 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 CPAP device. Our physician 
reviewer found based on the medical records provided there is no documentation that you meet the 
requirements listed in the LCD: L33718 for Medicare coverage as compliance with the Positive Airway 
Pressure (PAP) Device is not in compliance with the requirements of the LCD. Use of the device at least 4 
hours per night for only 32.2% of the time does not meet the LCD standard. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued rental of CPAP device (CPT Code E0601).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram provided on February 11, 2020, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the mammogram. You say that you were unaware prior authorization was 
required. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the 
provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the mammogram provided on February 11, 2020, 
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided on December 23, 
2019. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the claim was not billed according to CMS 
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. 
 
We find that CPT code A0429 is not supported in the record. Specifically, when a beneficiary was pronounced 
dead after the ambulance was called, the provider should report CPT code A0428 with modifier QL. This claim 
was billed with CPT code A0429, which is not appropriate in this case. Based on this information, we decided 
that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for ambulance services (A0429) provided on December 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a necessary treatment for the 
enrollee's condition. The Plan denied your request. The Plan says this is not a proven procedure at this time. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental. More research is needed to show 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 the Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve aspiration and injection (20610) and  injection, triamcinolone 
acetonide (J3304) of left knee. 
 
You asked the Plan to pre-approve aspiration and injection. You say that the cortisone shots do not work. You 
knee has locked up and you've had to call the ambulance several times because you were unable to move. The 
Plan denied your request. The Plan says that the records do not show that this procedure is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve aspiration and injection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has osteoarthritis of the left knee. She is status post right total knee 
replacement. She has had prior injections of cortisone and visco supplements but the degree and duration of 
relief was apparently brief. There is no documentation of recent PT, but this option may be very limited by the 
pandemic. The use of NSAIDs in an 86-year-old is also problematic. The request is for a trial of Zilretta. This 
medication affords the enrollee a longer duration of relief and is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aspiration and injection have been met. Therefore, we decided that the Plan has 
to pre-approve aspiration and injection (20610) and  injection, triamcinolone acetonide (J3304) of left knee.  
 
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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There 
are no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the health plan. Consequently, the requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the member 
needs more physical therapy and care to recover her condition. The Plan denied your request. The Plan says 
continued care could be provided in a skilled nursing facility or subacute rehab facility. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for aquatic therapy provided on November 1, 2019. 
 
You asked the Plan to pay for aquatic therapy. You say that the enrollee was pre-approved, so you provided 10 
visits. You say that the claims should be processed for payment.  The Plan denied your request. The Plan says 
the services are not payable. 
 
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 pay for aquatic therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the documentation does not reveal an inability to tolerate land 
therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pay for aquatic therapy provided on November 1, 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 would like reconsideration because 
the services requested are medically necessary. The Plan denied your request. The Plan says the guidelines for 
coverage of IRF care have not been met. 
 
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 enrollee still requires acute hospital level of care services and is receiving 
appropriate care at the present acute care hospital. The enrollee  does not require services at the LTACH that 
are not available at the acute care hospital where she is currently receiving 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 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 pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
February 19, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
 Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the 
enrollee on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership provided from January 17, 
2020, through May 18, 2020. 
 
You asked the Plan to reimburse you for the gym membership. The Plan denied your request. The Plan says the 
provider is not participating with the Plan's fitness provider. 
 
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 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 Plan fitness provider. Therefore, we decided that the Plan does not have to reimburse you for a gym 
membership provided from January 17, 2020, through May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary partial denture - flexible base (including any 
clasps, rests and teeth) (CPT Code D5225) and mandibular partial denture - flexible base (including any clasps, 
rests and teeth) (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not covered under Medicare or the Health Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The codes D5225 and D5226 are not listed in your contract as a 
covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to 
pre-approve maxillary partial denture - flexible base (including any clasps, rests and teeth) (CPT Code D5225) 
and mandibular partial denture - flexible base (including any clasps, rests and teeth) (D5226).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's anticipated goals cannot be achieved at 
a lower level of care due to lack of nursing care, rare therapy and absence of physician oversight. The Plan 
denied your request. The Plan says the medical records do not support the medical necessity criteria for 
inpatient rehabilitation services. 
 
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 there are no identified problems that need inpatient medical management. There are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The 
medical record supports a need for physical and occupational therapy but it does not support a need for an 
intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.