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

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on September 
20, 2021. 
 You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scan provided on September 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. 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 Gelsyn-3. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the Plan requires 
a trial of Orthovisc or Synvisc before they will approve the requested drug, Gelsyn-3. There is no indication 
that the patient has tried and failed the required drug(s). Based on the medical records provided there is no 
indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheel lock clamps, scissor locks, spinergy wheels, vinyl 
hand-rim covers, bearing forks, litespeed caster spacers, precision locks, caster for bearings, and quick release 
axles with logos for a manual wheelchair. 
 
You asked the Plan to pre-approve wheelchair components. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the denial of authorization for these components is correct, because 
these components are convenience features that are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The wheelchair components requested do not serve a purpose that is primarily medical in nature. These features are primarily for the comfort or convenience of the user. Therefore, we decided that the Plan does not have to 
pre-approve wheel lock clamps, scissor locks, spinergy wheels, vinyl hand-rim covers, bearing forks, litespeed 
caster spacers, precision locks, caster for bearings, and quick release axles with logos for a manual wheelchair.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to live independently and require a 
higher level of intervention. The Plan denied your request. The Plan says that you do not show a need for 
therapy or any other medical needs. 
 
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 SNF care. Our reviewer says that based 
on clinical documentation you require skilled nursing services. Our physician reviewer found you have a 
history of hypertension; it is documented that multiple medication adjustments were made and you would 
require close monitoring of blood pressure and to assess symptoms of low blood pressure, since you have 
cognitive impairments. You have new functional impairments in both mobility and activities of daily living, 
requiring physical assistance with bed mobility. Of a practical matter, you have had a clinical status change and 
would benefit from a combination of skilled therapy and skilled nursing services on a daily inpatient basis. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastrointestinal (GI) tract imaging (91110). 
 
You asked the Plan to pre-approve GI imaging. You say that you have been experiencing unexplained pain 
following a gallbladder surgery, and this service is necessary to proceed with your treatment. The Plan denied 
your request. The Plan says this procedure is not found to be helpful or useful in producing improvements in 
health outcomes in the treatment of unexplained abdominal pain. This procedure is used to look for sources of 
bleeding and you do not have any complaints of gastrointestinal bleeding or unexplained anemia. Therefore, 
this service 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 pre-approve GI imaging. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that you have abdominal pain which is considered to be due to irritable 
bowel disease. The record indicates that you have previously undergone cholecystectomy and had two normal 
colonoscopies. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied; the requested service is not 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 GI imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve gastrointestinal (GI) tract imaging (91110).
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 a medical necessity for you. The Plan 
denied your request. The Plan says medical necessity 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, to meet medical necessity for an IRF stay, you must require intense therapy in at 
least 2 disciplines (one discipline being physical or occupational therapy). Based on the available documentation, you do not require intense therapy by two disciplines of therapy. The clinical documentation 
also reports poor participation; thus it would not be expected that you would be able to tolerate 3 hours per day, 
5 days per week. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on October 31, 2021. You asked the Plan to pay for the lab services. You say that the testing provides physicians with the most up-
to-date treatment options. The Plan denied your request. The Plan says one code must be submitted for the 
panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that a Tempus gene panel was provided. We looked at the file and the rules. In this case, the 
panel was billed with multiple codes. If a single procedure is performed, only one code with one unit of service 
may be reported for the procedure.  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 testing 
provided on October 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from November 16, 
2021, to December 15, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you have always followed the 
guidelines as communicated by the Plan. The Plan denied your request. The Plan says the non-contracted 
provider did not submit the RAP claim for services for date of service November 16, 2021, to December 15, 
2021 until January 5, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided from November 16, 2021, to December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
no the medical documentation. The Plan denied your request. The Plan says this claim has not been billed 
appropriately based on Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says you do not use insulin with at least three daily injections and require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that this is medically necessary. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because the clinical value and 
effectiveness of IGRT for the enrollee's condition has not been demonstrated. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for the palliative treatment of benign joint conditions with low doses, the use of IGRT is 
generally considered not medically necessary outside of a medically plausible rationale. In this case, it is not 
clear what benefit IGRT would afford, and it appears IGRT is simply being used as routine practice. As there 
does not seem to be any exceptional circumstances for the enrollee necessitating IGRT, there is no rationale for 
the need for IGRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) provided 
on May 4, 2021. 
 
You asked the Plan to pay for the therapeutic CGM. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the criteria for coverage of payment of 
DME items have not been met. 
 
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 relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records provided do not indicate the provider discussed the medical 
necessity of the ordered equipment with the enrollee. 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 therapeutic continuous glucose monitor (CGM) provided on May 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says step therapy rules for the requested drug 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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Ferrlecit, Sodium Ferric Gluconate, Infed, Venofer, and oral iron before they will 
approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no 
documentation provided indicating that the Plans required drugs 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme (Q0138).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that someone 
in your mothers building where she resides saw her fall. You also say that you do not think the ambulance 
service was necessary, as it was not a critical situation. The Plan denied your request. The Plan says your 
mother received treatment on-site and refused transportation to the hospital. The Plan also says that the 
Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there 
is no Medicare covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 14, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shower chair provided on September 20, 2021. 
 
You asked the Plan to pay for the shower chair. The Plan denied your request. The Plan says the billed supply 
code cannot be verified. The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
We looked at the file and the rules. While a shower chair may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item. The record does not contain valid proof of delivery for the supplies 
provided in this case. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the shower chair provided on September 20, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services have not been met. 
 
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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).