Persius/hicric huggingface dataset:
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
hip fracture after a fall. The enrollee's medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show enrollment in an approved category B investigational device 
exemption (IDE) study 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this circumstance therapy change based on data obtained from a CardioMEMs device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.  
Moreover, concerns have been raised about potential bias in this trial calling into question the results.   
Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met 
since the device should still be considered experimental or investigational. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS HF device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ajovy for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this drug has had a significant improvement in the 
enrollee's migraine headaches. The Plan denied your request. The Plan says that this is not covered under 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 Ajovy for the enrollee.  
 
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a battery. You say that you need a battery when the power goes out. The 
Plan denied your request. The Plan says Medicare does not pay separately or make an additional payment for 
backup equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a battery backup for a continuous positive airway pressure 
(CPAP) device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of an inpatient skilled nursing facility admission. 
 
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 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee 
does not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter 
the enrollee 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 inpatient skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cancer Detect Extended genetic cancer risk panel 
provided on December 31, 2019. 
 
You asked the Plan to pay for the genetic cancer risk panel. You say that this is medically necessary to 
determine the enrollee's risk of developing cancer. The Plan denied your request. The Plan says the claim was 
billed with a place of service code that cannot be verified based on the records. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic panel provided was done in the absence of a personal history of any type of cancer and without any 
reported signs/symptoms of cancer. This means it was performed for screening purposes and is not among the 
 
 
Medicare-covered screening tests. Therefore, we decided that the Plan does not have to pay for the Cancer 
Detect Extended genetic cancer risk panel provided on December 31, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laryngoscopy provided by a participating 
provider on July 2, 2020. 
 
You asked the Plan to waive the copayment for a laryngoscopy. You say that you think this should be covered. 
The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for outpatient diagnostic tests/diagnostic tests.  
 
You have been asked to pay a $15 copayment for a laryngoscopy. A laryngoscopy falls within the outpatient 
diagnostic tests/diagnostic tests benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
laryngoscopy provided by a participating provider on July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad (E0218). 
 
You asked the Plan to pay for the fluid circulating cold pad. You say that you would like reconsideration 
because you were prescribed this equipment for use after knee surgery. The Plan denied your request. The Plan 
says this equipment is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad have not been met. Specifically, this equipment is not a Medicare 
covered benefit. Therefore, we decided that the Plan does not have to pay for a fluid circulating cold pad 
(E0218).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Androgel. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Androgel.  
 
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation is not clear that your mobility deficit impairs participation in the MRADLs in the home. Your 
mobility deficit is currently helped by a walker. The documentation is not clear that you would be able to safely 
operate and maneuver the wheelchair in the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
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. The Plan denied your request. The Plan says Medicare coverage 
criteria have not been met for admission to an acute IRF. 
 
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. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. Our physician reviewer also found that the available 
documentation raises doubt that you would be reasonably expected 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology procedure, level 8 (NRAS) (81407), 
molecular pathology procedure, level 9 (LDLR) (81408), BRAF gene analysis (81210) and PTEN gene 
analysis (81323) provided on March 6, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services rendered were medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 molecular pathology procedure, level 8 
(NRAS) (81407), molecular pathology procedure, level 9 (LDLR) (81408), BRAF gene analysis (81210) and 
PTEN gene analysis (81323) provided on March 6, 2020, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab Xgeva Injection 120MG. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says step therapy encourages the member to try the Plan's  preferred, equally effective 
drug(s): intravenous pamidronate or zoledronic acid. 
 
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 medication. Our physician reviewer 
found the review indicates that the Plan requires a trial of drug intravenous pamidronate OR zoledronic acid 
before they will approve the requested drug. In this case, the patient has not tried and failed the required 
drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Denosumab Xgeva Injection 120MG.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 25, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99152) provided on May 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older". 
 
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 code 99152 is not supported by the records provided. Our coding reviewer found that the operative 
report does not document that an independent trained observer to assist in monitoring the patient's level of 
consciousness and physiological status was present during procedure.  Therefore, CPT 99152 cannot be 
verified. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 99152) provided on May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies (A4253, A4256, A4258, A4259 
and E0607) provided. 
 
You asked the Plan to pay for the testing supplies. You say that you would like reconsideration because the 
supplies provided are medically necessary. The Plan denied your request. The Plan says the medical 
documentation submitted did not include a valid physician order for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. 
Specifically, the physician order is over one-year-old and the proof of delivery does not indicate that these 
supplies were delivered to the enrollee on the billed date of service. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the diabetic testing supplies (A4253, A4256, A4258, A4259 and E0607) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for office visits. 
 
You asked the Plan to pre-approve the physician's services for office visits. The Plan denied your request. The 
Plan says the Plan does not cover non-emergency services by a non-contracted provider, when a contracted 
provider can provide the 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 services at issue in this appeal. 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 
physician's services for office visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device (22869, 22870). 
 
You asked the Plan to pre-approve the interspinous spacer device. You say that the spacer placement is 
medically necessary. The Plan denied your request. The Plan says the requested service is considered 
investigational and experimental and is not covered. 
 
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 interspinous spacer device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the spacer device requested is considered experimental in this application. More 
research is needed to prove 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 interspinous spacer device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an interspinous spacer device (22869, 22870).