Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) injections. 
 
You asked the Plan to pre-approve the requested SIJ injections. You say that you feel that these injections 
should be approved to help your pain. The Plan denied your request. The Plan says this is not a supported 
treatment for your condition. 
 
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 requested SIJ injections. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found SIJ injections are recommended as an option if the patient has failed at least 4-6 
weeks of aggressive conservative therapy, including physical therapy (PT), home exercise and medication 
management. There should be evidence of a clinical picture that is suggestive of sacroiliac injury and/or 
disease. At least three positive exam findings of SI joint dysfunction should be present on physical exam such as: Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. 
 
In this case, there is no documentation on physical examination of tenderness of the SI joint and no mention of 
SI provocative testing being completed with positive findings. The clinical value and effectiveness of an SIJ 
injection in the absence of tenderness and negative provocative testing results has not been demonstrated in the 
peer-reviewed literature. The review has determined that the enrollee does not have a diagnosis/condition that 
meets the criteria for the requested services. The requested sacroiliac joint injection 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 requested SIJ injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac joint (SIJ) injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 
26, 2021, to November 27, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the attending physician thought this 
would take longer than one day for the enrollee to improve. You also say that the services should be covered. 
The Plan denied your request. The Plan says the inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record does not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from November 26, 2021, to November 
27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya for the enrollee. 
 
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Ilumya. Our reviewer says that Ilumya 
is not medically reasonable and necessary. There is no indication that the patient has tried and failed Stelara. 
There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse 
effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy 
criteria for Ilumya. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure. 
 
You asked the Plan to pre-approve a Minuteman procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman procedure is experimental. 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 a Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need the additional 
routine transportation trips being requested so that you can finish physical therapy. The Plan denied your 
request. The Plan says the enrollee has exceeded the benefit limit for routine transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The record shows that the Plan has 
provided coverage for 52 one-way routine transportation trips in the 2022 calendar year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation and management services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON evaluation and management services. You say that without the 
procedure your health and wellbeing will decline to the point where you may never be able to meet your base 
level or to the point where you become critically ill. You say that you are needing to have the surgery 
procedure to remove a Whipple. The Plan denied your request. The Plan says there are network providers who 
are able to supply the enrollee with the treatment required. 
 
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 
evaluation and management services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from June 
6, 2022, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this enrollee does not 
meet the criteria for June 6, 2022, forward as this enrollee was not shown to be a danger to their self or others, 
delusions, auditory or visual hallucinations noted. The enrollee was cooperative/compliant with treatment while 
not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from June 6, 2022, forward.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 40 additional routine transportation trips. 
 
You asked the Plan to pre-approve the 40 additional routine transportation trips. You say that you have several 
medical appointments including wound care, urology, brain and spine, ear nose and throat, and gastrointestinal 
services. The Plan denied your request. The Plan says the enrollee will exceed benefit limits with the additional 
trips requested. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way routine transportation trips per year.  
 We looked at your request, the records in the case file, and the rules. The records show that, at the time of your 
request, the Plan had provided coverage for 59 one-way routine transportation trips in the 2022 calendar yar. 
Based on this information, we decided that your request would exhaust the Plan maximum benefit for coverage 
of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 40 additional 
routine transportation trips.
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 stay is not medically necessary based on IRF criteria. 
 
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 require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 
has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
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 rehabilitation at home is not helping. The Plan 
denied your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 
has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99310) provided on August 
3, 2021. 
 
  You asked the Plan to pay for subsequent nursing facility care (99310). You say that the physician provided 
medically necessary services to the member in good faith and the services meet professionally recognized 
standards of healthcare. You say that the doctor is seeking reimbursement and you expect payment to be 
processed timely. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care (99310) provided on August 
3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remodulin (J3285). 
 You asked the Plan to pre-approve Remodulin. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, intravenous 
treprostinil. 
 
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 Remodulin. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred generic 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 
generic alternative. Therefore, the elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remodulin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Remodulin (J3285).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service February 
2, 2022. 
 You asked the Plan to pay for procedure code 76705-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 76705-26 is bundled into 
payment for code 93976. 
 
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 
76705-26 is a column II code to column I code 93976. 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 procedure code 76705-26 billed for date of service 
February 2, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve behavioral health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON behavioral health services. You say that this is medically 
necessary treatment. The Plan denied your request. The Plan says this is an OON provider, and there are 
network providers able to provide this care. The enrollee also has a long term care plan that includes coverage 
for this, so this is a duplication of 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 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 behavioral health services to be provided by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing received on February 3, 2022. 
 
You asked the Plan to pay for the COVID-19 testing. You say that you had to receive this testing due to a 
cruise you had been planning for over a year. The Plan denied your request. The Plan says the services received 
are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.  
Review of the file does not show that the testing received was ordered by a physician. This testing was 
completed prior to going on a trip through a cruise line. This means that the COVID-19 test at issue in this 
appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing received on 
February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services provided on August 4, 2021. 
 
You asked the Plan to pay for the services provided. You say that the claim should be reprocessed allowing full 
benefits. The Plan denied your request. The Plan says the claim lacks information for adjudication. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, must furnish to the 
intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 We looked at the file and Medicare rules. The file shows that CPT code 86769 was billed twice on the same 
date of service. There are no lab results or medical records in the case file. There is no indication as to why two 
tests were performed or the reasoning for the testing. There are insufficient records to show that the CPT code 
is supported. Therefore, we decided that the Plan does not have to pay for the testing services provided on 
August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
October 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. 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 services provided by an out-of-network provider on October 
8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on November 1, 2021. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on November 1, 
2021.