Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTAC 
admission criteria. You say that this requires a hospital setting with wound care, and hospitalist daily rounding, 
which is provided at the LTACH. The Plan denied your request. The Plan says based on Medicare guidelines 
the LTACH services you are requesting do not meet the requirements for approval. 
 
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. Our 
physician reviewer found the enrollee with a history that includes heart failure, diabetes, and hypertension was 
hospitalized on July 22, 2022 with a perforated duodenal ulcer. The enrollee underwent surgery for 
gastrectomy and resection and had a feeding tube placed. The recovery was complicated by septic shock, 
hemorrhagic shock, atrial fibrillation, kidney injury, encephalopathy, and respiratory failure. The enrollee also 
had a breakdown of the surgical wound and is being treated with a wound vacuum system.  
 The enrollee requires bilevel positive airway pressure at night, intravenous diuretics and is being followed by 
Endocrinology. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) for cervical spine 
(72156), and MRI for thoracic spine (72157). 
 
You asked the Plan to pre-approve the MRIs. You say that the enrollee needs these services. The Plan denied 
your request. The Plan says the requested MRIs are not medically reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRIs. Our reviewer says that the 
requested MRIs are not medically reasonable or necessary. Our physician reviewer found the provided 
documentation does not support that an MRI of the thoracic spine with and without contrast, and an MRI of the 
cervical spine with and without contrast are medically reasonable and necessary for the enrollee in this case. 
 
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 MRIs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) for cervical spine (72156), and MRI for thoracic spine 
(72157).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the enrollee's records do not show that they need to be seen by a rehabilitation 
doctor at least 3 times a week or that they are able to take part in 3 hours of therapy a day at least 5 days a week 
or that the enrollee needs an intensive team. The Plan states the enrollee can safely receive the services they 
need in other settings, for example: a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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 the enrollee does not have complex rehabilitation needs.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Monovisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zilretta injection for the right knee. 
 
You asked the Plan to pre-approve the Zilretta injection. You say that this works better than Cortisone, and a 
second dose of Zilretta will help you not be in pain. The Plan denied your request. The Plan says you 
previously received a Zilretta injection in your right knee on May 11, 2022. The Plan also says that according 
to the FDA prescribing guidelines, Zilretta injections have not been demonstrated (shown) to be safe and 
effective for repeat use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Zilretta injection. Our reviewer says 
that the Zilretta injection is not reasonable and necessary. Our physician reviewer found the efficacy and safety 
of repeat administration of Zilretta have not been demonstrated. 
 
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 Zilretta injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Zilretta injection for the right knee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
 
 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 Prolia. Our reviewer says that Prolia is 
not reasonable and necessary for the enrollee. Our physician reviewer found there is no indication that the 
enrollee has tried and failed the required drug, Zoledronic acid. Our reviewer also found that there is no 
indication that the Plan's required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) 
provided on March 17, 2022. 
 
You asked the Plan to pay for the ultrasonic guidance for needle placement. The Plan denied your request. The 
Plan says the clinical value and effectiveness of ultrasonic guidance for the needle placement of superficial 
trigger point injections have not been demonstrated to improve outcomes or efficacy 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 pay for the ultrasonic guidance for needle 
placement. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Health Plan has already approved the trigger point 
injections. Our reviewer also found that the clinical value and effectiveness of ultrasonic guidance for the 
needle placement of superficial trigger point injections have not been demonstrated to improve outcomes or 
efficacy in the peer-reviewed literature. 
 
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 ultrasonic guidance for needle placement have not been met. Therefore, we 
decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided 
on March 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you are appealing the denial of SNF 
admission. The Plan denied your request. The Plan says based on the available clinical information we have 
determined that the enrollee's status does not meet severity or intensity medical necessity criteria for SNF level 
of care. 
 
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 the enrollee is reported to be medically stable for discharge on outpatient medications including oral 
antibiotics. Our physician reviewer found the enrollee with a past medical history of hypertension, heart failure, 
atrial fibrillation, depression and a pacemaker presented to the acute hospital on August 1, 2022 with diarrhea, 
hypotension and hyponatremia. The enrollee was also found to have methicillin-resistant staphylococcus aureus 
bacteremia and was treated in the hospital with intravenous antibiotics and condition has stabilized. The 
enrollee is weak and deconditioned and is working with physical and occupational therapy. The enrollee is 
walking 80 feet with a wheeled walker with contact guard assistance and is contact guard assist for transfers 
and is stand-by to minimum assist activities of daily living. The enrollee does not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee 
does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a 
skilled professional therapist. Our reviewer also found that the enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 the SNF admission.  
 
Your complaint about the facility giving the enrollee the wrong medication and they have also mixed 
medications they were not supposed to do is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-eight (28) fractions of PBT (IGRT). 
 
You asked the Plan to pre-approve the services. You say that there are particular circumstances in this 
enrollee's case that make proton beam therapy a superior treatment for them. The Plan denied your request. The 
Plan says here is no current research showing that the enrollee's type of cancer responds better to the requested 
type of treatment than the type of treatment the Pan can approved. 
 
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 there is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation 
therapy, Intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
The most recent American Urological Association (AUA) guidelines state that PBT offers no clinical 
advantage over other forms of definitive 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty-eight (28) fractions of PBT (IGRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder x-ray (procedure code 73030) provided to the 
enrollee on March 18, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says an anatomical modifier was not appended. 
 
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 73030 is "Radiologic examination, shoulder; complete, 
minimum of 2 views." 
 
We asked our coder 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 x-ray. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that a shoulder x-ray was performed, and 
billed with modifier 26. These services should be reported with the appropriate anatomical modifier in addition 
to modifier 26. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for a shoulder x-ray (procedure code 73030) provided to the enrollee on March 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening (G0103) provided on July 12, 
2021. 
 
You asked the Plan to pay for the prostate cancer screening. You say that you were told you would be covered 
for this test. The Plan denied your request. The Plan says this benefit was exhausted as of September 8, 2020. 
The Plan also says there is not a record of any calls from you prior to or on this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that prostate specific antigen tests are covered at a 
frequency of once every 12 months.  
 
We looked at the file and Medicare rules. Medicare and plan rules state that prostate cancer screening is only 
covered once per year, and you have exhausted the Plan limit. Based on this information, we decided that 
Medicare rules for coverage of the prostate cancer screening have not been met. Therefore, we decided that the 
Plan does not have to pay for the prostate cancer screening (G0103) provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Heme testing (81455) provided on December 
23, 2021. 
 
You asked the Plan to pay for FoundationOne Heme testing. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary.  
 
We looked at the file and Medicare rules. The testing at issue was submitted with code 81455. Based on this 
information, we decided that Medicare rules for coverage of FoundationOne Heme testing have not been met.  
 
 
 
 Therefore, we decided that the Plan does not have to pay for FoundationOne Heme testing (81455) provided on 
December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on January 26, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a consultation 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 have 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 
a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on September 26, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit services provided by an OON provider. You say that you would 
like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
received were provided by an OON provider without prior authorization. The Plan says there were in-network 
urgent care facilities available to you at the time you received these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 had network providers 
available who could have provided 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 office visit services provided on September 26, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (32666) provided April 1, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be billed as paid. 
 
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 CPT code 32666 is not supported in the medical record. Specifically, a required anatomical 
modifier was missing. Based on this information, we decided that Medicare rules for coverage of the surgical 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services 
(32666) provided April 1, 2022.