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

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injection. You say that these injections help you. The Plan denied 
your request. The Plan says the denial of authorization for these services is correct, because your previous 
injection only had 30% continued pain relief. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered if certain 
clinical criteria have been met. 
 
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 facet joint injection. Our reviewer says 
that you do not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found 
the medical records state that you are not currently receiving physical therapy, are not on a home exercise 
program, and have not received physical therapy or continuation of home exercises in the previous 6 months. 
Nonsteroidal anti-inflammatory drugs (NSAIDs) are not contraindicated and there has not been a trial of 
NSAIDs for greater than 6 weeks. You had previous medial branch blocks with initial 100% pain relief lasting 
for hours, but 30% continued relief as documented by the ability to perform household chores with less pain. 
Therefore, the requested injections are not 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 facet joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet joint injections.
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. The Plan denied your request. The Plan says it is not 
clear that the enrollee will benefit from the long term care requested 
 
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 the enrollee was admitted to the current acute care hospital with anemia, shortness of 
breath, and congestive heart failure. She has low blood pressure, atrial fibrillation, and requires close 
monitoring and treatment of her low blood count. Recent notes state that her status is guarded. She appears to 
need more time in the acute care hospital to further stabilize prior to consideration of transfer. The enrollee 
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 at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits with a provider not within your local 
network. 
 
You asked the Plan to pre-approve the office visits. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says your care could be safely managed by a doctor in your 
plan's local network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
It has been determined that your care could be safely managed by a doctor in your plan's local network. The 
requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visits with a provider not within your local network.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that the requested OON provider has been your primary care physician for over 30 years. You say that your new in-network primarycare physician doesn't want to see you for another 6 months. You say that the requested OON provider is much more thorough and is aware of your medical conditions and needs. You say that you are 94 years old and that your health is failing.The Plan denied your request. The Plan says there are in-network providers available who can treat your conditions and supply the care needed.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient care provided from February 16, 2020, to February 19, 2020.You asked the Plan to pay forinpatient care. You say that it is not clear if the enrollee lost consciousness.The Plan denied your request. The Plan says the records do not document loss of consciousness.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the definition of the billed diagnosis code S06.5X9A is traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter.We find that the billing of S06.5X9A is not supported in the medical record. Specifically, the records do not document that the enrollee lost consciousness. Based on this information, we decided that Medicare rules for coverage of inpatient care have notbeen met.Therefore, we decided that the Plan does not have to pay forinpatient care provided from February 16, 2020, to February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on November 25, 2019. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the use of a telecommunications system may substitute 
for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited 
number of other physician fee schedule (PFS) services. 
 
The file shows that the laboratory services at issue were ordered via telehealth. Medicare does not allow for 
these services to be ordered via telehealth. Therefore, we decided that the Plan does not have to pay for the 
genetic testing rendered on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve a complete upper denture and complete lower denture. You say that the 
items are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
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 complete 
dentures once every 5 years.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a complete upper denture and complete lower denture have not been met. The plan covers 
complete dentures once every five years. The record shows that you received complete lower and upper 
dentures on June 30, 2020. This means that you are not eligible for health plan coverage of complete dentures 
at this time. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110) and complete lower denture (D5120).
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 you appear to be improving and requires less than 25 days of additional acute care 
services. You do not require services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that the patient requires that are not already available and covered at the current 
facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 
Transfer to a lower level of care may be considered soon. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on 
January 14, 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 enrollee did not have prior authorization for out of network care. 
 
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 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 out of network lab services 
provided to the enrollee on January 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria has not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve long-term wearable electrocardiographic monitoring. 
 
You asked the Plan to pre-approve long-term wearable electrocardiographic monitoring (93228, 93229). You 
say that the enrollee continues to have palpitations and needs long-term wearable electrocardiographic 
monitoring . The Plan denied your request. The Plan says that WEM is not 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 long-term wearable 
electrocardiographic monitoring (93228, 93229). Our reviewer says that the requested items/services are 
considered medically reasonable and necessary in this case. Our physician reviewer found based on the records 
the enrollee has persistent palpitations that apparently were not captured with a 24-hour Holter monitor. In this 
circumstance since symptoms are documented to persist some longer-term off line monitoring such as an event 
monitor is reasonable and appropriate to evaluate for dysrhythmias during less frequent symptoms. Coverage 
criteria for long-term event monitoring are met based on the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of long-term wearable electrocardiographic monitoring (93228, 93229) have been 
met. Therefore, we decided that the Plan has to pre-approve long-term wearable electrocardiographic 
monitoring.  
 
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 pre-approve the LINX reflux management system. 
 
You asked the Plan to pre-approve the LINX system. You say that this is needed to treat the enrollee's GERD. 
The Plan denied your request. The Plan says this procedure remains experimental 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 LINX system. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a female with symptoms of anterior and substernal chest pain, heartburn, 
regurgitation, and acid taste in the mouth which is attributed to gastroesophageal reflux disease (GERD). There 
is documentation of multiple ER visits for non-cardiac chest pain and the need for repair of a large 7cm 
retrocardiac hiatal hernia.  
 
It is clear that the enrollee believes she has GERD; however, there is no pH recording to correlate her 
symptoms with reflux events. Given her normal lower esophageal sphincter (LES) tone and function, 
augmentation of the LES by implantation of LINX does not appear to be medically necessary. Furthermore, the 
LINX treatment should be approached with caution in this case and may even be contraindicated due to the 
documentation of a large unrepaired hiatal hernia, which her provider has indicated is a likely factor in the 
enrollee's recurrent chest pain. 
 
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 LINX system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the LINX reflux management system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 12, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until July 30, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on May 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on January 10, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  
 
We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate that 
critical care services were rendered on the billed date of service. Based on this information, we decided that 
Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care services (99291) provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chemotherapy administration (96413), therapeutic 
injection (96375), chemotherapy administration push single drug (96409), and introduction of needle (36000) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve chemotherapy and injection. You say that you wish to continue receiving 
services from this provider because they have treated you before and you communicate well together. The Plan 
denied your request. The Plan says there are in-network doctors who can perform these services that offer 
translation services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the chemotherapy administration (96413), therapeutic injection (96375), chemotherapy administration push 
single drug (96409), and introduction of needle (36000) to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that services can be provided at lower 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physicianreviewer 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-approveskilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network home health provider. 
 
You asked the Plan to pre-approve the referral. You say that the denial is a mistake as there has been an 
authorization for this in the past. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network home health provider.