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

 
We decided that the Plan does not have to pre-approve aflibercept (Eylea) injection (J0178). 
 
You asked the Plan to pre-approve aflibercept (Eylea) injection (J0178). You say that the enrollee has been 
successfully treated with aflibercept (Eylea) in the past. The Plan denied your request. The Plan says the 
medical record documents that the provider administered one dose of Eylea on February 10, 2023. The Plan 
also says there has been no other prior treatment, and no prior authorization was obtained. 
 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 aflibercept (Eylea) injection (J0178). 
Our reviewer says that the enrollee does not meet the criteria for the requested medication. Our physician 
reviewer found the enrollee has not demonstrated failure or intolerance to Avastin. Our physician reviewer also 
found that therefore, it is medically reasonable to treat with intravitreal Avastin injection, per the Plan's step 
therapy policy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aflibercept (Eylea) injection (J0178) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve aflibercept (Eylea) injection (J0178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that without non-invasive ventilator therapy, the enrollee 
is at high risk for hospital readmission and potentially life-threatening exacerbations. The Plan denied your 
request. The Plan says the record does not show that the enrollee failed BiPAP therapy, instead the enrollee 
improved with BiPAP. The Plan also says that the enrollee's needs could be met by a BiPAP device with 
average volume-assured pressure support (AVAPS) and a back-up rate. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide CPAP or 
BiPAP therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on November 3, 
2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that medical records were provided. The Plan 
denied your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the moderate sedation services provided on November 3, 2022, billed with code 99153.
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 the enrollee meets full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF, 
therapy may safely be done at a lower level of care. 
 
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 needs for frequent physiatry oversight. The IRF 
is not a medical step down unit for persons who do not require or cannot participate in intensive rehabilitation.  
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: 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 the enrollee is having problems with balance, 
strength, endurance, inability to rise from a chair without assistance, and is requiring the use of an assistive 
device and hands on assistance for ambulation and meets full Inpatient Acute Rehabilitation criteria. The Plan 
denied your request. The Plan says the enrollee records do not show the need an intensive team for care, 
services needed can be provided safely in a lower level of care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar endoscopic L4-5 transforaminal discectomy. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar endoscopic L4-5 transforaminal discectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for an LTACH admission. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on June 21, 2022. 
 
You asked the Plan to pay for the radiology services as billed. You say that the claim was billed properly and 
should be paid. The Plan denied your request. The Plan says code 77014 is incidental to another service and 
cannot be paid. 
 
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. Specifically, the Plan did not support its denial as there is no documentation 
showing the service in which the denied code is bundled. Therefore, we decided that the Plan does not have to pay for radiological services provided on June 21, 2022. In addition, we could not make a determination about 
the services provided on June 20, 2022, because there was no waiver of liability for that date.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve laser treatment for psoriasis (96921). 
 
You asked the Plan to pre-approve laser treatment for psoriasis. You say that the treatment was done before and 
worked well. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 laser treatment for psoriasis. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found excimer laser treatment of this enrollee is within the standard of 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 laser treatment for psoriasis have been met. Therefore, we decided that the Plan 
has to pre-approve laser treatment for psoriasis (96921).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service June 13, 
2022. 
 You asked the Plan to pay for procedure code 88321. You say that the documentation shows medical necessity. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 88321 billed for date of 
service June 13, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the rehabilitation services provided from January 3, 2022, to January 
12, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were submitted via certified 
mail. The Plan denied your request. The Plan says that the medical records submitted did not include 
documentation for the billed date of service. 
 
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. 
 
We looked at the file and the rules. The case summary shows that medical records were submitted with the 
appeal on October 27, 2022. The Plans denial also states that medical records were submitted. The appellant 
confirms that records were submitted. However, the Plan did not provide the records that were submitted for 
this case. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the 
rehabilitation services provided from January 3, 2022, to January 12, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 11, 2021. 
 
You asked the Plan to pay for the lab services. 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, for 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 the lab services provided on October 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Latuda. 
 
You asked the Plan to pre-approve Latuda. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Latuda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery and a specialist office 
visit provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery and a specialist office visit. You say that 
you disagree with the copayments. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment and a $30 copayment for outpatient surgery/Medicare-covered outpatient surgery and 
physician/practitioner services/specialist.  
 
You have been asked to pay a $200 copayment and a $30 copayment for an outpatient surgery and a specialist 
office visit. The total amount you are being asked to pay for all services $230 ($200 + $30 = $230). This 
item/service falls within the outpatient surgery/Medicare-covered outpatient surgery and physician/practitioner services/specialist benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery 
and a specialist office visit provided on February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a forearm x-ray and a wrist x-ray provided on August 8, 
2022, by an OON provider. 
 
You asked the Plan to pay for a forearm x-ray and a wrist x-ray. You say that you are requesting 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the enrollee must 
receive care from a network provider. 
 
 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 a forearm x-ray and a wrist x-ray provided on 
August 8, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal coronary angioplasty; single 
major coronary artery or branch (92920) and percutaneous transcatheter placement of intracoronary stent(s), 
with coronary angioplasty when performed; single major coronary artery or branch (92928). 
 
You asked the Plan to pre-approve percutaneous coronary intervention. You say that you are requesting 
reconsideration because you are having trouble breathing. You are tired and fatigued. You do not feel you can 
wait another 30 days for surgery. The Plan denied your request. The Plan says your records do not show that it 
is medically reasonable to pursue cardiac catheterization or stenting currently in the work up of your problems, 
without other less invasive cardiac testing and evaluation first. 
 
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 Percutaneous Coronary Intervention. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have a history of a typical chest pain at rest and an abnormal ECG. 
Non-invasive cardiac workup, such as stress test or coronary CT angiography, has not been performed. 
Documentation does not support the rationale for this invasive imaging study. As a result, at this time cardiac 
catheterization and percutaneous transluminal coronary angioplasty would not be considered medically 
appropriate and necessary in your 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 Percutaneous Coronary Intervention have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous transluminal coronary angioplasty; single major 
coronary artery or branch (92920) and percutaneous transcatheter placement of intracoronary stent(s), with 
coronary angioplasty when performed; single major coronary artery or branch (92928).
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. The Plan denied your request. The Plan says the enrollee's needs 
including physical and occupational therapy can be met at a lower level of care such as a skilled nursing 
facility. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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.