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

 
We decided that the Plan does not have to pay for the services provided on May 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit have not been met. Specifically, the record shows that the claim 
was billed with primary diagnosis code, R65.10. This code has a code first note, which means it is a 
manifestation code and must be sequenced after an etiology code. Therefore, we decided that the Plan does not 
have to pay for the services provided on May 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe surgical services provided on May 29, 2020.You asked the Plan to waive the coinsurance forthe surgical services. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the surgical services on May 29, 2020. You are asked topay 5% coinsurance for the services. Your EOC states that enrollees must pay 5% coinsurance for each outpatient hospital visit. 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 coinsurance forthe surgical services provided on May 29, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF care.You asked the Plan to pre-approveSNF care. You say that the stay is necessary.The Plan denied your request. The Plan says the stay is not 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 based on the documentation provided, the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to 
the enrollee. 
 
You asked the Plan to pre-approve continuation of inpatient mental health 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continuation of inpatient mental health 
care. Our physician reviewer found based upon review the records provided, this patient does not meet the 
criteria for treatment in an acute inpatient mental health treatment beyond the date in question of October 15, 
2020, forward and could have been treated in a lesser restrictive setting as the patient was not showing any 
suicidal or homicidal ideation, but did have auditory hallucinations no visual hallucinations and was not 
showing any behaviors being cooperative and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of inpatient mental health care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to the 
enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit for the enrollee. 
 
You asked the Plan to pre-approve Procrit. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet step therapy criteria. 
 
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 Procrit. Our reviewer says that Procrit 
is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and failed 
Retacrit. There is no documentation provided indicating that Retacrit is likely to be less effective and/or likely 
have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet 
step therapy criteria for Procrit. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 22, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the outpatient services (80053, 83540, 83550, 82728, 82607, 82746, 84443, 
84439, 84480 and 85025). You say that you would like reconsideration because these services were medically 
necessary and rendered in good faith. The Plan denied your request. The Plan says the provider did not obtain 
authorization for the services rendered. 
 
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 medical services provided on May 22, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CardioMEMS device.You asked the Plan to pre-approvethe CardioMEMS device. You say that the device is necessary.The Plan denied your request. The Plan says the device is not necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer says that the requested items/services are 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 CardioMEMS device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided on October 1, 2019, to 
October 22, 2019, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skilled nursing services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
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 skilled nursing services provided on October 1, 
2019, to October 22, 2019, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider 
on May 13, 2020. 
 
You asked the Plan to pay for the services. You say that the state of Missouri does not require referrals. The 
Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 laboratory services provided by an out-of-network 
provider on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre CGM system. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is important to adjust your medications. 
The Plan denied your request. The Plan says the most recent records from your physician indicate that you are 
only taking two insulin injections per day and check your blood sugar only twice per day. 
 
 
 
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 CGM. Our physician reviewer 
found although you may benefit from libre 2 with alerts and alarms, you do not meet the Medicare criteria for 
CGM use provided above; namely you are not injecting insulin three times daily and not checking BGS 4 times 
daily. Therefore, you do not meet criteria as above. Our physician states that we are also not told why you 
cannot check more often and what you blood glucose (BG) pattern is on the daily (QD) Tresiba and if you have 
low BGS on this QD insulin which causes less hypoglycemia than nph/regular. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Freestyle Libre CGM system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the life alert system. 
 
You asked the Plan to pre-approve the life alert system. You say that the member needs the device because 
they have fallen twice in the shower. The Plan denied your request. The Plan says this device is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The rules say that Telephone Alert Systems are not covered because emergency communications systems do 
not serve a diagnostic or therapeutic purpose. Therefore, we decided that the Plan does not have to pre-approve 
the life alert system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagoscopy (43180) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an esophagoscopy 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 
an esophagoscopy (43180) to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is a candidate for 
restorative services. The Plan denied your request. The Plan says hospice can provide nursing service if needed. 
 
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.  
 
We looked at the file, and Medicare rules. The records show that the Plan has agreed to pre-approve rehab 
therapy services. Due to the enrollee being on hospice, we found no indication which would require the Plan to 
further approve additional services. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled 
nursing services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a POEM procedure. 
 
You asked the Plan to pre-approve a POEM procedure (43499). You say that this is the best treatment for the 
enrollee's medical condition. The Plan denied your request. The Plan says that this procedure does not have 
enough proof to support the safety and success of its use. 
 
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 Per-Oral Endoscopic Myotomy 
(POEM) procedure (43499). Our reviewer says that the requested services are considered medically reasonable 
and necessary in this case. Our physician reviewer found POEM, as proposed for enrollee, is not listed by 
American College of Gastroenterology as a recommended treatment option. However, comparison with 
conventional treatment approaches is available. As such, POEM is not investigational for the enrollee's 
indication, and is medically necessary (with greater likelihood of benefit than available standard approaches) 
for treatment of the enrollee's condition. Denial is overturned. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Per-Oral Endoscopic Myotomy procedure (43499) have been met. Therefore, 
we decided that the Plan has to pre-approve a Per-Oral Endoscopic Myotomy procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the documentation did not show how much relief the enrollee received from the previous injection. The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections 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 you have chronic low back pain. On magnetic resonance imaging (MRI), you have foraminal stenosis and ligamentum favum thickening. The documentation does not clearly state the degree and duration of the pain relief from prior ESI injections. You have been non-compliant with physical therapy and a home exercise program. You also have not been trialed with other conservative therapies. The requested procedure is therefore, 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 epidural steroid injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CTA, abdominal aorta and bilateral iliofemoral lower 
extremity runoff, with contrast material(s), including noncontrast images, if performed, and image 
postprocessing (CPT Code 75635). 
 
You asked the Plan to pre-approve the CTA. You say that the scan is necessary. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CTA. Our physician reviewer found 
the patient recently reported chronic chest pain, shortness of breath with walking, and swelling of the right leg. 
There was no report of claudication. Physical findings included intact peripheral pulses, 1+ edema, erythema, 
wounds on the right leg. Prior ankle-brachial index (ABI) was normal, no recent ABI noted. Slow healing of 
the wounds was noted. CTA, abdominal aorta and bilateral iliofemoral lower extremity runoff with contrast 
was requested. CTA would only be justified in the setting where clinical presentation and objective physical 
findings or simpler testing such as with pulse oximetry and/or ABI suggests a likely vascular obstruction or 
defect. This patient has no such evidence to support CTA. Therefore, this request for CTA will be considered 
not medically 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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CTA, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast 
material(s), including noncontrast images, if performed, and image postprocessing (CPT Code 75635).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Decipher Prostate Assay provided to the enrollee on May 
20, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the clinical documentation in the case file does not support that the results of the Decipher Prostate 
Assay testing was used to determine whether this enrollee was traditionally considered to be high risk of 
recurrence after radical prostectomy (RP), and could be closely followed, rather than receive post-operative 
radiation therapy (XRT). 
 
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 pay for the Decipher Prostate Assay provided to the enrollee on May 20, 2019.