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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is needed. The Plan denied your request. 
The Plan says you do not require daily skilled services. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the beneficiary is a female who was treated with right shoulder replacement. From a 
nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital 
signs. Regarding rehabilitation services, the beneficiary received physical and occupational therapy. The 
beneficiary was at a supervision to stand by assist level for functional mobility including gait to 100 feet. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, such services are not required on a daily basis. This beneficiary does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 25, 2021, billed with 
codes 81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291 and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services are supported in the 
medical records provided. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare rules. 
 
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 genetic testing provided on 
June 25, 2021, billed with codes 81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291 and 81240.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84439 and 84481 billed for date of service 
February 10, 2021. 
 
You asked the Plan to pay for 84439 and 84481. You say that these services were reported correctly. The Plan 
denied your request. The Plan says the payment for these services is bundled into the payment for other 
services billed on this claim. 
 
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 84439 
is a column II code to column I code 84479 and 84481 is a column II code to column I code 84480. Both of 
these code pairs have a modifier indicator of 0. The column II codes are therefore not payable. 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 codes 84439 and 84481 billed for date of service February 10, 2021.
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 this item will be used for the treatment of 
OSA and OHS. The Plan denied your request. The Plan says a BiPAP would meet the patient's needs. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found This patient has untreated 
obstructive sleep apnea (OSA), obesity hypoventilation syndrome, and heart failure with preserved ejection 
fraction, with a recent hospitalization for a gastrointestinal bleed.  The patient's arterial blood gas is consistent 
with acute on chronic hypercarbic respiratory failure. There are no diagnoses of chronic obstructive pulmonary 
disease, thoracic restrictive disease, or neuromuscular disease. This patient would likely benefit from continuous positive airway pressure (CPAP) or BiPAP during sleep. Medicare does not cover a home ventilator 
in the treatment of OSA or obesity hypoventilation syndrome (OHS).  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve lumbar laminectomy decompression with Coflex stabilization. 
 
You asked the Plan to pre-approve lumbar laminectomy decompression with Coflex stabilization. You say that 
the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 lumbar laminectomy decompression 
with Coflex stabilization. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found Coflex is an interlaminar stabilization 
device that is indicated for one or two level lumbar stenosis from L1 to L5. Based on the current medical 
literature, interspinous spacer interventions for symptomatic lumbar spinal stenosis have been shown to be safe 
and effective through 5 years of follow-up. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar laminectomy decompression with Coflex stabilization have been met. 
Therefore, we decided that the Plan has to pre-approve lumbar laminectomy decompression with Coflex 
stabilization.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says Lucentis is a non-preferred product, and the 
enrollee does not have any stated contraindications to the preferred products. The Plan says that the enrollee 
has not tried any of the preferred agents and the provider has not supplied a rationale for use of the non-
preferred product for safety or efficacy.  
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 Lucentis. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of exudative 
age-related macular degeneration of the left eye with choroidalneovascularization. The Plan requires a trial of 
drug Avastin before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the plans required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110) provided on April 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting additional payment for 
procedure code prophylaxis D1110. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay 70% of the billed 
amount for the prophylaxis (D1110) and the oral evaluation (D0120). You are responsible for any amount 
greater than what the Plan pays to the out-of-network provider. Therefore, we decided that the Plan does not 
have to pay more for prophylaxis (D1110) provided on April 20, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the enrollee meets all the requirements for coverage 
and not getting the requested drug will negatively affect the enrollee's health. The Plan denied your request. 
The Plan says the enrollee does not have any stated contraindications to the preferred products. The Plan says 
that the enrollee has not tried any of the preferred agents and does not provide a rational for use of the non-
preferred product for safety or efficacy.  
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 Injectafer. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of iron 
deficiency anemia. The Plan requires a trial of drugs Ferrlecit, INFeD or Venofer before they will approve the 
requested drug. In this case, the enrollee has not 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 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64490, 64491, 77003, and 81002 billed for 
date of service August 5, 2021, to October 21, 2021. 
 
You asked the Plan to pay for procedure codes 64490, 64491, 77003, and 81002. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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 codes 64490 and 64491 are 1. The MAI value for this code is 2. You billed 2 
units of this code, exceeding the MUE. Both codes were billed twice with modifier LT (left) and RT (right). 
These are not the correct modifiers if bilateral surgical procedures were performed. This means these codes are 
not payable as billed with both modifiers. 
 
In this case, we have confirmed that code 77003 is an add-on code and has not been billed with an appropriate 
primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. 
 
In this case, we have confirmed that code 81002 is a column II code to column I code 80307. 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 codes 64490, 64491, 77003, and 81002 
billed for date of service August 5, 2021, to October 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 1, 
2022, through March 22, 2022, and March 25, 2022, through March 27, 2022. 
 
You asked the Plan to pay for SNF care. You say that the SNF stay was medically necessary. The Plan denied 
your request. The Plan says the enrollee no longer required daily skilled services at the SNF level of care and 
there were no other acute or unstable medical conditions documented requiring skilled services. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that the 
enrollee required skilled nursing services. Our physician reviewer also found that services in the nursing 
facility appeared custodial in this case with part time therapy services provided from March 1, 2022, through 
March 22, 2022, and March 25, 2022, through March 27, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 1, 2022, through March 22, 2022, and 
March 25, 2022, through March 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. 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 power wheelchairs are covered when specific 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 a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
record does not indicate the enrollee can safely use the wheelchair or that her clinical environment requires a 
motorized wheelchair or can accommodate one. 
 
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 group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a filling (D2150) and a crown (D2751) for 
tooth #5 and #15 provided on April 14, 2022. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that you would like the 
coinsurance waived. The Plan denied your request. The Plan says the provider did not provide any information 
on why they used a more costly material; therefore, the proper coinsurance was charged for the least costly 
method/procedure. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers 
a dental benefit in excess of Medicare coverage, the requested items or services are 
among those covered under this benefit with a coinsurance applied. The total amount allowed for the filling 
was $142 with a coinsurance of $28.40 ($142 total amount x 20% coinsurance). The enrollee responsibility 
between the allowed amounts was $51; therefore, the total amount the enrollee is responsible for the filling is 
$79.40 ($28.40 coinsurance + $51 difference in allowed amounts. The total amount allowed for the crown was 
$918 with a coinsurance amount of $459 ($918 total amount allowed x 50% coinsurance). The enrollee 
responsibility between the allowed amounts was $129; therefore, the total amount the enrollee is responsible 
for the crown is $588 ($459 coinsurance + $129 total amount allowed). The total amount for the dental services 
the enrollee is responsible for is $667.40 ($79.40 total amount for the filling + $588 total amount for the 
crown). Therefore, we decided that the Plan does not have to waive the coinsurance for a filling (D2150) and a 
crown (D2751) for tooth #5 and #15 provided on April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 6, 2021, billed with 
codes 81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291 and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says these services were not billed in accordance 
with Medicare rules. 
 
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 genetic testing provided on 
July 6, 2021, billed with codes 81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291 and 81240.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective 
left shoulder total reverse arthroplasty. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee needs surgery. The Plan 
denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
 
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 that documentation is not evident regarding a significant past and/or current medical 
history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient 
stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the record does not show that at the time of inpatient 
admission, the admitting physician would reasonably expect that the enrollees necessary hospital 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 associated with an elective left shoulder total 
reverse arthroplasty.