Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that this is medically 
necessary. The Plan denied your request. The Plan says the records do not support further treatment. 
 
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 10 additional physical therapy visits. 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 records show that the enrollee has 
had prior therapy and is compliant in a home exercise program. The enrollee does not require the unique skills 
of a professional therapist to safely and effectively provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that you are homebound or have skilled needs. 
 
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. A doctor must certify the need for home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the documentation doesnt support that you requore additional skilled nursing services or skilled rehab services 
to provide treatment that is medically necessary. You do not require additional skilled nursing or rehab services 
to effectively provide treatment, care, and/or services in order to improve your condition, perform a 
maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations. You have a caregiver at 
home that can help with custodial care. The requested home health services are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test kits purchased on January 8, 2022, and 
January 11, 2022. 
 
You asked the Plan to pay for the COVID-19 test kits. You say that you would like to be reimbursed for the 
COVID-19 test kits. The Plan denied your request. The Plan says people with Medicare will not be eligible to 
be reimbursed for COVID-19 tests purchased before April 4, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for claims with dates of 
service starting on or after April 4, 2022, through the last day of the COVID-19 public health emergency 
(PHE), and claims should be submitted to Original Medicare for patients enrolled in a Medicare Advantage 
(MA) plan.  
 
We looked at the file and Medicare rules. Over the counter (OTC) tests for dates of service April 4, 2022 and 
after are paid for. OTC tests before April 4, 2022 are only covered if the Plan has a supplemental benefit for 
them. Centers for Medicare & Medicaid Services (CMS) instructs that for a Medicare Advantage beneficiary, 
the claim for the test should be submitted to Original Medicare instead of the Plan. Therefore, we decided that 
the Plan does not have to pay for the COVID-19 test kits purchased on January 8, 2022, and January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on July 
11, 2021. 
 
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 the place of service was inappropriate for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT 99152 and 99153 have a Professional Component (PC)/Technical Component (TC) Indicator, which 
means technical component only. 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 moderate sedation 
services provided to the enrollee on July 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation procedure (CPT 
code 64624). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of a genicular nerve radiofrequency 
ablation in the setting of knee osteoarthritis have not been demonstrated in the peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve ablation is experimental for knee pain treatment. More research is needed. 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 pre-approve genicular nerve radiofrequency ablation procedure (CPT code 64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot/knee, ankle unit, extra protective 
cover, pelvic suspension and a prosthetic leg. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is unable to ambulate, and the current 
prosthesis is ill-fitting. The Plan denied your request. The Plan says a request for replacement prosthesis with 
K3 functional level components does not meet Medicare criteria as reasonable and 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested items exceed your medical needs. The documentation is inconsistent that you are at a 
K3 level. The documentation indicate that you were approved for a K0823 group 2 power wheelchair on 
5/20/22, for that rationale that you were unable to use a prosthetic. 
 
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 pre-approve an advanced foot/knee, ankle unit, extra protective cover, pelvic suspension and a 
prosthetic leg.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus (J2350). 
 
You asked the Plan to pre-approve Ocrevus (J2350). You say that this drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Ocrevus (J2350). Our reviewer says 
that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the Plan 
requires a trial of Kesimpta before they will approve the requested drug. The record indicates that the enrollee 
has relapsing multiple sclerosis. The requested medication is a new start. The provided records do not indicate 
that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that 
the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ocrevus (J2350) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Ocrevus (J2350).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing services provided from January 20, 2022, to January 31, 
2022. 
 
You asked the Plan to pay for skilled nursing services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says that the denial of payment for these services is correct, because this was 
submitted as a claim for physician component services and should be submitted as a claim for facility services 
instead. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that this claim was submitted on the inappropriate claim form. 
However, the Plan has only submitted an internal electronic claim screenshot and has not submitted a copy of 
an original claim form. Therefore, we cannot determine whether this claim was submitted in the appropriate 
format given the type of provider and services rendered. Therefore, the Plan has not shown that its decision to 
deny payment for this claim is correct or justified according to Medicare rules. Therefore, we decided that the 
Plan has to pay for skilled nursing services provided from January 20, 2022, to January 31, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 6, 
2022. 
 
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 an appropriate place of service for CPT 85060. 
 
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 85060 is "Blood smear, peripheral, interpretation by 
physician with written report." 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, no payment can be 
recognized for this code when billed as hospital outpatient. 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 laboratory services provided to the enrollee on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT code 64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; second level (CPT code 64494). 
 
You asked the Plan to pre-approve the injections. You say that you are in pain every day and it is hard to get 
out of bed. The Plan denied your request. The Plan says your request is not medically necessary because your 
records show you have new right foot and ankle weakness consistent with a radiculopathy that has not yet been 
treated. The Plan states you also have multi-level pathology on magnetic resonance imaging (MRI) which has 
not been addressed as an alternate pain generator. 
 
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 injections. Our physician reviewer 
found the requested procedure is not medically necessary because the records show you have new right foot 
and ankle weakness consistent with a radiculopathy that has not yet been treated. You also have multi-level 
pathology on magnetic resonance imaging (MRI) which has not been addressed as an alternate pain generator. 
Therefore, the request is 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
code 64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (CPT 
code 64494).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 that the patient was admitted for wound infection, weakness, and confusion. 
 Medical problems are stable. 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. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. In conclusion, 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the SNF 
services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 
require daily skilled nursing and/or skilled therapy on 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Dental Services from January 12, 2021 to November 17, 2021. 
 
You asked the Plan to pay for Dental Services. You say that you were not informed that the provider was not 
in-network. The Plan denied your request. The Plan says the provider is on the Medicare opt-out list and for 
this benefit, you can see any licensed provider, in the U.S., that isn't on the opt-out list. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for Dental 
Services from January 12, 2021 to November 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Prolia is covered if the patient is adequately 
supplemented with calcium and vitamin D. 
 
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 Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the record indicates that 
the enrollee is not receiving calcium supplementation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that 
you have bone loss, and your dentures are not working for you. You also say that you are unable to chew and 
have to swallow your food whole, which is causing you more issues. The Plan denied your request. The Plan 
says these services exceed the maximum counts allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) 
and mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture (D5110) on March 11, 2020 and you received a 
mandibular partial denture (D5214) on December 6, 2018, and your complete maxillary denture (D5110) and 
mandibular partial denture (D5214) benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transthoracic Echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that a TTE is medically necessary. The Plan denied your 
request. The Plan says a Transthoracic Echocardiography does not meet the Plan's Medical Policy coverage 
criteria. 
 
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 TTE. Our reviewer says that the 
requested TTE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
at issue is the medical necessity for performance of a repeat TTE in a patient with no interim change in clinical 
condition. The guidelines do not support a need for TTE in this setting. As a result, at this time TTE would not 
be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a TTE.