Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that you want the enrollee treated with this drug. The 
Plan denied your request. The Plan says the enrollee has not first tried and had an inadequate response to 
Orthovisc and Monovisc. 
 
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 Synvisc-One. Our reviewer says that 
the drug is not reasonable or medically necessary. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatment with Orthovisc. Step therapy, as outlined by the plan, requires that both Monovisc 
and Orthovisc be trialed first. The documentation does not outline contraindications or reasons that Orthovisc 
was not considered. Without the support of the documentation, Synvisc-One is not approved, as step therapy 
criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 22, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 the requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on April 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued stay at a skilled nursing facility (SNF) after 
November 18, 2020. 
 
You asked the Plan to pre-approve the continued stay at a SNF. You say that the enrollee needs continued SNF 
care. The Plan denied your request. The Plan says the enrollee no longer requires skilled services and the 
continuation of SNF care 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 the continued stay at a SNF. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no 
identifiable skilled nursing service needs and no identifiable skilled therapy service needs. Furthermore, our 
doctor also found that the beneficiary does not require skilled nursing or therapy services on a daily basis and 
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 the continued stay at a SNF have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued stay at a skilled nursing facility (SNF) after November 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with CT (78815). 
 
You asked the Plan to pre-approve the PET with CT. You say that you would like reconsideration because you 
run out of air, get tired quickly but cannot sleep at times. The Plan denied your request. The Plan says this is 
not the appropriate imaging study for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET with CT. Our reviewer says 
that you do not meet Medicare coverage criteria for the PET with CT. Our physician reviewer found the 
documentation shows that the findings are not strongly suspicious of cancer and are more consistent with 
another condition. 
 
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 PET with CT have not been met. Therefore, we decided that the Plan does 
not have to pre-approve PET with CT (78815).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out of network
(OON) provider on November 2, 2018.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
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 did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the laboratory services rendered by the out of network (OON) provider on
November 2, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the requested device is being used in the bilevel PAP mode rather than 
being used as a home ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. You have chronic obstructive pulmonary 
disease and have been prescribed biPAP as a nocturnal respiratory assist device. The requested AVAPS adapto-
servo ventilation technology (function that adapts pressure support to patient needs to guarantee an average 
tidal volume) is available on an E0471 device (e.g. Phillips Dream Station BiPAP with AVAPS or Resmed 
Stellar 100/150). You do not have life-threatening conditions where interruption of respiratory support would 
quickly lead to serious harm or death. You do not have neuromuscular disease, thoracic restrictive disease, or 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found 
that your condition does not meet Medicare criteria for a portable ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy. 
 
You asked the Plan to pre-approve the Proton Beam Radiation Therapy. You say that you would like 
reconsideration because the member's medical needs are complex and this service is medically necessary. The 
Plan denied your request. The Plan says Proton Beam Therapy for primary treatment of prostate cancer should 
only be performed within the context of a prospective clinical trial. 
 
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 Proton Beam Radiation Therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there are no compelling data to suggest that proton therapy is superior 
to or more beneficial than IMRT/IGRT. Proton therapy would arguably exceed the member's need. 
 
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 Proton Beam Radiation Therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Proton Beam Radiation Therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer. 
 
You asked the Plan to pre-approve the Vertiflex Interspinous Spacer. You say that you would like 
reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says this 
device is experimental and investigational. 
 
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 Vertiflex Interspinous Spacer. 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 and 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 Vertiflex Interspinous Spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Vertiflex Interspinous Spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says the effectiveness, side 
effects, recovery time and long term outcomes of this procedure have not been well established. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support 
the use of this device for this enrollee's medical condition. Superion indirect lumbar decompression would not 
be considered the standard of care for the enrollee's medical condition. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower limb prosthesis coded with L5828, L5856, 
L5845, L5930, L5987, L5964, L5984, L5986 and L5848 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the requested K3 components exceed the member's needs and cannot be 
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 these services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. The 
documentation is not consistent that the patient is a K3 or above ambulator. The L5828, L5856 and L5848 are 
not medically necessary as these are covered for patients whose functional level is 3 or above. A high activity 
knee control frame (L5930) is covered for patient whose functional level is 4 which is not the case with this 
patient. An L5987 shank foot system with vertical loading pylon (L5987) is covered for patients whose 
functional level is 3 or above. The Flexible Protective Outer Surface Cover (L5964) exceeds your medical 
needs as there is no documentation that you require this for harsh or wet environmental exposure. The L5848 
knee-shin sys fluid stance extension exceeds your medical need as you are not a K3 ambulator. The L5984 and 
L5986 exceed your functional needs as the advanced foot is not medically necessary. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lower limb prosthesis coded with L5828, L5856, L5845, L5930, L5987, L5964, L5984, 
L5986 and L5848
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift purchased March 25, 2020. 
 
You asked the Plan to pay for a stair lift. You say that the stair lift is medically necessary. You wouldn't be able 
to get outside without it. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift purchased March 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic service provided on June 10, 2020. 
 
You asked the Plan to pay for the radiologic service. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the diagnosis submitted is not covered according to policy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The diagnosis is allergic rhinitis. There are no specific radiologic 
findings for confirming the diagnosis. Based on this information, we decided that Medicare rules for coverage 
of the radiologic service have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiologic service provided on June 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
still requires acute level of care hospital services and is receiving appropriate care at the present acute care 
facility. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that a significant decline in endurance and ability to 
complete transfers was noted. The Plan denied your request. The Plan says the enrollee does not require skilled 
services on a daily basis. 
 
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 physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and her 
lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee 
was at a moderate to maximal assist level with functional mobility. She required varying assist with activities 
of daily living. There are no identifiable skilled therapy service needs. She does not require skilled nursing or 
therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cervella Cranial Electrotherapy Stimulator. 
 
You asked the Plan to pre-approve a Cervella Cranial Electrotherapy Stimulator. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says electrosleep therapy is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Until scientific assessment of electrosleep therapy has been 
completed and its efficacy is established, no payment will be made by Medicare. Based on this information, we 
decided that Medicare rules for coverage of a Cervella Cranial Electrotherapy Stimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Cervella Cranial Electrotherapy Stimulator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy. 
 
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration 
because the additional physical therapy is medically necessary. The Plan denied your request. The Plan says the 
submitted clinical notes do not document improvement. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional physical therapy. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the documentation does not support that the enrollee's 
condition has the potential to improve or is improving in response to therapy, that maximum improvement is 
yet to be attained; and that there is an expectation that the anticipated improvement is attainable in a reasonable 
and generally predictable period of 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 additional physical therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on June 15, 2020. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that NGS panels must be billed with procedure code 
81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on December 30, 2019. 
 
You asked the Plan to pay for genetic tests. You say that you use the referring physician's order form as the 
sole basis for rendering the required tests. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because these tests are not covered by Medicare under the circumstances.  
 
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 tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover 
these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic 
screening testing provided on December 30, 2019.