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

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 18, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. You also say that your physician provided 
medically necessary services to the member in good faith. The Plan denied your request. The Plan says services 
from non-participating providers are not covered unless preauthorized. 
  
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 subsequent nursing facility care provided on 
February 18, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physician pathology services provided on December 27, 2021, 
billed with codes 88305-26 and 88311-26. 
 
You asked the Plan to pay for the professional component of the pathology services. You say that there was a 
facility claim submitted for these services which was paid. The physician billing group then submitted the 
professional claim for the professional component of the billed services. These are payable in the inpatient 
place of service. The Plan denied your request. The Plan says that the claim was denied for inconsistent place 
of service. However, no appeal decision was made by the Plan. 
 
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. The Plan has not provided documentation to support denial of payment in this 
case. The professional component of physician pathology is payable in the inpatient setting. Without a clear 
rationale, we find that the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay 
for the physician pathology services provided on December 27, 2021, billed with codes 88305-26 and 88311-
26.  
 
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 pre-approve the ExoDx Prostate IntelliScore (EPI) genetic testing 
service. 
 
You asked the Plan to pre-approve the ESI testing services. You say that this testing is medically necessary for 
your condition. The Plan denied your request. The Plan says the criteria for coverage are not met for this 
testing.  
The Plan must follow Medicare rules. Medicare rules say that an enrollee must not have a relative indication 
for a prostate biopsy including a first-degree relative with prostate cancer.  
 
We looked at the file and Medicare rules. In this case, the record confirms that you have a first-degree relative 
who was diagnosed with prostate cancer. Based on this information, we decided that Medicare rules for 
coverage of the ESI testing services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ExoDx Prostate IntelliScore (EPI) genetic testing service.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that the 
requirements for coverage of Durolane have not been met. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc, or Synvisc-One before they will approve the requested drug. The submitted records 
do not show that the enrollee has tried and failed any of these drugs. The records also do not indicate that these 
drugs would be less effective or 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 12 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 12 PT visits. You say that the enrollee will benefit from additional physical 
therapy for strengthening and gait training. The Plan denied your request. The Plan says that the requested 
physical therapy visits 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 12 PT visits. Our reviewer says that the 
requested 12 PT visits are medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee is making objective improvements and not all reasonable goals have been met. 
Therefore, the reviewer found that the 12 additional physical therapy sessions are 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 12 PT visits have been met. Therefore, we decided that the Plan has to pre-
approve 12 physical therapy (PT) visits.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the CardioMEMS device is considered unproven and 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS device (CPT code(s): 33289 and C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses equipment (L1833, L2397, L2810) provided on 
March 24, 2022. 
 
You asked the Plan to pay for the orthoses equipment. You say that this equipment is medically necessary for 
your condition. The Plan denied your request. The Plan says the documentation submitted did not sufficiently 
support the billed supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the medical records do not indicate that the ordering provider discussed the medical 
need for the ordered equipment with the enrollee. Therefore, we decided that the Plan does not have to pay for the orthoses equipment (L1833, L2397, L2810) 
provided on March 24, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS). 
 You asked the Plan to pre-approve rTMS treatment. You say that the enrollee should qualify for rTMS 
treatment. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for rTMS. 
 
The Plan follows Medicare rules. Medicare rules state that repetitive transcranial magnetic stimulation (rTMS) 
is only covered if certain criteria are met. 
 
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 rTMS treatment. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested rTMS treatment. Our physician reviewer 
found this is being requested for treatment of major depressive disorder. The enrollee has tried medications and 
is undergoing psychotherapy. Electroconvulsive treatment was declined. Medicare coverage of rTMS requires 
confirmation of the diagnosis of severe major depressive disorder, and resistance to treatment with 
psychopharmacologic agents as evidenced by a lack of clinically significant response to trials of 4 agents in the 
current depressive episode from at least 2 different agent classes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rTMS treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve repetitive transcranial magnetic stimulation (rTMS).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on February 15, 2022. 
 
You asked the Plan to pay for the services provided. 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 code. 
 
 
 
 In this case, the CPT Code Manual definition of code 73600 is radiologic examination, ankle; 2 views. We find 
that CPT code 73600 was not billed with a modifier to indicate which ankle the services were provided on.  
Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on February 15, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the requested services. You say that you cannot care for yourself. The Plan 
denied your request. The Plan says the approved visits have had no significant impact to the needs of the 
enrollee. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician 
reviewer found that you do not have documented skilled nursing needs (i.e., IVs, complex wound care, new 
ostomy). You have a chronic wound. Despite months of treatment, the wound persists. The treatment being 
provided is not complex. There is an available and willing caregiver.  As such, the requested, ongoing, home 
health skilled nursing services are not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 enrollees medical condition appear stable on outpatient medications with no 
issues that appear to require a physicians evaluation three or more times per week. The enrollee does not 
require the intensive medical care and the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. The medical records do not clarify that treatment at the skilled nursing facility level is 
not appropriate 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 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 laminectomy with exploration and/or decompression of 
spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 
vertebral segments; lumbar, except for spondylolisthesis (CPT code 63005). 
 
You asked the Plan to pre-approve the services. You say that the enrollee's health will be negatively impacted if 
the procedure is delayed. The Plan denied your request. The Plan says the services are 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, the formal magnetic resonance imaging 
(MRI) report was not provided for review to corroborate the pathology in the lumbar spine. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the CPT 63005- laminectomy with exploration and/or decompression of 
spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 
2 vertebral segments; lumbar, except for spondylolisthesis, in this case, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, 
without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, 
except for spondylolisthesis (CPT code 63005).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) admission 
from August 26, 2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee needs continued physical 
therapy, occupational therapy and wound care. The Plan denied your request. The Plan says criteria for a 
continued SNF stay have not been met. 
 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 continued SNF care. Our reviewer says 
that continued SNF care is not medically reasonable and necessary. Our physician reviewer found that you do 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, 
and judgment of a skilled professional therapist. You do 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continued skilled nursing facility (SNF) admission from August 26, 2022, 
forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cabazitaxel (J9043), chemotherapy administration 
(96413) provided on March 26, 2022. 
 
You asked the Plan to pay for Cabazitaxel. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the enrollee has not had prior therapy with a docataxel containing regimen 
for treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pay for Cabazitaxel. Our reviewer says that the 
coverage criteria for the requested drug have not been met. Our physician reviewer found the record provided does not indicate that the enrollee was previously treated with a docetaxel-containing treatment regimen.  The 
Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that 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 Cabazitaxel have not been met. Therefore, we decided that the Plan does not 
have to pay for the Cabazitaxel (J9043), chemotherapy administration (96413) provided on March 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 1, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider has no prior 
knowledge of which patients he/she will be required to see. You also say that once the provider arrives at the 
facility, he/she receives a list of patients who require treatment and provides services to all of them, since there 
is currently no in-network doctor who can treat the patients in this facility. The Plan denied your request. The 
Plan says the rendering provider is out-of-network with the Plan. The Plan also says that authorization was not 
obtained prior to the services being rendered. 
 
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 domiciliary or rest home visit provided on 
November 1, 2021, by an out-of-network (OON) provider.