Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. 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 Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the records have not shown 
that you 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 you. 
 
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 Feraheme.
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. Your representative says that you need rehab for your leg that is
giving you pain. They say that you are the primary care giver to your son so it is important to get the
rehabilitation that you need. The Plan denied your request. The Plan says based on the documentation received
you do not meet the criteria for admission to an acute rehabilitation 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 you do not require the intensity of services provided at an IRF. Specifically, you
do not show that you require fifteen hours per week of rehabilitative services and regular physician evaluation.
Your needs can be met at a lower level of care, for example skilled nursing facility, subacute rehabilitation
care, or home health services.
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial upper denture (D5820). 
 
You asked the Plan to pre-approve the dental item. You say that you need a new partial denture due to bone 
loss. You say that the denture is for your front teeth. You also say that you do not want to be without front teeth 
until you are able to get actual dentures. The Plan denied your request. The Plan says interim partial denture is 
not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested interim partial denture is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
an interim partial upper denture (D5820).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet injection. 
 
You asked the Plan to pre-approve a facet injection. 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. 
 The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 facet injection. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no need for repeat diagnostic 
blocks. Repeat RFA is the next step here. The request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a facet injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a facet injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this provider is experienced and draws blood the 
first time. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
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 lab services provided on March 22, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. Arterial blood gas (ABG) was consistent with acute hypercarbic respiratory failure. There is no 
diagnosis of chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, or neuromuscular 
disease. The enrollee may benefit from continuous positive airway pressure (CPAP) or bilevel positive airway 
pressure (BiPAP) during sleep in the treatment of obstructive sleep apnea (OSA). But Medicare does not cover a home ventilator for this diagnosis. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 97530, 97112 and G0283. We decided that the Plan 
does not have to pay for procedure code 97010.  You asked the Plan to pay for physical therapy services. You say that these services were pre-approved for 
twelve visits and were denied incorrectly. The Plan says that payment for code 97010 is bundled into the 
payment for other services. 
 
We decided that the Plan has to pay for procedure codes 97530, 97112 and G0283.  
 
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, your appeal includes an authorization number for these services. 
The Plan has not provided information or an argument for the continued denial of these services, and the Plan 
has not stated or provided evidence that these services have been overturned and paid. Therefore, we decided 
that the Plan has to pay for procedure codes 97530, 97112 and G0283.  
 
We also decided that the Plan does not have to pay for procedure code 97010. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
billing 97010 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
97010. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 20, 2022. 
 
You asked the Plan to pay for the medical services. You say that you timely filed this claim so it should be 
paid. The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 14, 2022. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on February 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the somatic molecular genetic panel provided on March 15, 
2022, billed with codes 81455, 81479, 81301 and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services are supported in the 
medical records. The Plan denied your request. The Plan says these services were not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the somatic molecular genetic 
panel provided on March 15, 2022, billed with codes 81455, 81479, 81301 and 81194.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that without physical therapy you are unable to do 
your daily activities. The Plan denied your request. The Plan says these services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program.  There is no documentation to support significant 
improvement in function or pain levels with physical therapy. The additional therapy services are not an 
appropriate duration and frequency for treatment of your medical condition and therefore are not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five physical therapy visits.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a therapeutic agent injection. 
 
You asked the Plan to pre-approve a therapeutic agent injection. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who meet specific criteria. 
 
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 therapeutic agent injection. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee meets the 
criteria. The request for radiofrequency ablation (RFA) is medically reasonable and 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 a therapeutic agent injection have been met. Therefore, we decided that the Plan 
has to pre-approve a therapeutic agent injection.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee has heart failure and 
hypertension. The Plan denied your request. The Plan says the enrollee does not have prior heart monitoring 
that was unrevealing. 
 
The Plan follows Medicare rules. Medicare rules say that outpatient cardiac telemetry is only covered under 
certain medical indications.  
 
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 device. Our physician 
reviewer found that the enrollee has a history of bradycardia and daily palpitations. As such, guidelines would 
not support a need for MCOT monitoring in this setting. In summary, there is insufficient documentation to 
support the medical necessity for an MCOT monitor in this patients 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an implant (D6100), endosteal implants 
(D6010), implant surgery (D6011), bone grafts (D6104), and guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the removal of an implant (D6100), endosteal implants (D6010), 
implant surgery (D6011), bone grafts (D6104), and guided tissue regeneration (D4266) are not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of an implant (D6100), endosteal implants (D6010), implant surgery (D6011), bone grafts (D6104), 
and guided tissue regeneration (D4266).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 20 additional routine transportation trips for 2022.
You asked the Plan to provide additional routine transportation. You say that you have used all of your
transportation for the year and need additional trips to continue attending your appointments. The Plan denied
your request. The Plan says your plan covers a maximum of 72 routine transportation trips per year. Additional
trips are not a covered benefit.
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 Plan's coverage rules apply in this
case. The Plan covers a maximum of 72 trips per year.
We looked at your request, the records in the case file, and the rules. 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 provide 20 additional routine transportation trips for 2022.
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 this is the best facility for you to receive help for her 
everyday living. You say you were totally independent before getting sick. The Plan denied your request. The 
Plan says authorization because the IRF care is not medically necessary, and your needs can be met at a lower 
level of care such as a skilled nursing facility (SNF), 
 
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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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 pay for procedure codes 63048 and 20937 billed on February 25, 
2022. 
 
You asked the Plan to pay for procedure codes 63048 and 20937. You say that the information supports CPT 
codes 63048, 20937 and 22214. The Plan denied your request. The Plan says procedure code 22214 has been 
overturned. The Plan also says procedure codes 63048 and 20937 are not supported by the medical records 
submitted. 
  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 procedure codes 63048 is laminectomy, facetectomy and 
foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, 
spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or 
lumbar (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 
20937 is autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or 
fascial incision) (List separately in addition to code for primary procedure). 
 
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 procedure codes 63048 and 20937. Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not describe a laminectomy, facetectomy and foraminotomy with decompression of 
spinal cord. The operative report also does not describe the physician making an incision over the ilium, fibula, 
or other site from which the autograft will be obtained. Therefore, these procedures 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 procedure codes 63048 and 20937 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 63048 and 20937 billed on February 25, 2022.