Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
sepsis, pneumonia, congestive heart failure, pulmonary edema and was discharged home with home health services on April 1, 2022. Your medical problems are stable. 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 you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain without 
contrast material (70450) provided on November 9, 2021. 
 
You asked the Plan to pay for the CT. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) of the head or brain without 
contrast material (70450) provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator with settings that could be 
delivered by BiPAP with Average volume-assured pressure support (AVAPS) for this member with COPD is 
not covered. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. The record indicates that the enrollee has 
chronic respiratory failure from chronic obstructive pulmonary disease.  The provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS 
capability. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a 
portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326) injections. 
 
You asked the Plan to pre-approve Gel-One injections. You say that the best treatment would be Gel-One 
injections to relieve the enrollee's pain due to their age and it not being a muscle issue. The Plan denied your 
request. The Plan says the requested injections are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Gel-One injections. Our reviewer says 
that the requested injections do not meet the criteria for coverage. Our physician reviewer found the record 
does not indicate that the enrollee has tried and failed conservative non-pharmacologic therapy and simple 
analgesics. The reviewer found that the Food and Drug Administration (FDA) has not stated that the requested 
drug is indicated for the enrollee's condition. The Medicare approved 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 Gel-One injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Gel-One (J7326) injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the ear (70480) 
provided on June 14, 2021. 
 
You asked the Plan to pay for a CT scan of the ear. You say that you have provided records to support the level 
of service. The Plan denied your request. The Plan says the service at issue is included in another billed code.  
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 70480 
is a column II code to column I code 70450. 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 a computed tomography (CT) scan of the ear (70480) provided 
on June 14, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc. 
 
You asked the Plan to pre-approve Genvisc. 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 Genvisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee is noted to have osteoarthritis 
of the knees, for which she has previously received GenVisc injections. Despite these injections, the enrollee is 
still having knee pain. According to the FDA label, The effectiveness of repeat treatment cycles of GenVisc 
850 has not been established. As such, the request for repeat treatment with GenVisc is 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 Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
November 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
November 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the safest discharge plan for 
allows for the highest potential level of recovery. The Plan denied your request. The Plan says the denial of 
authorization for LTACH service is correct. 
 
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 the enrollee appears to be currently unstable and should only require short-term 
additional acute care service that can be safely administered at the current facility until more stable for transfer. 
The enrollee does not require services at the LTACH that are not already available at the current facility. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, bevacizumab. 
 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 Eylea. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not show 
that the enrollee has tried and failed the plan's preferred drug, bevacizumab. The reviewer found that the 
medical records provided do not indicate that the plan's required drug would likely be less effective and/or 
likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676) and segmental 
pneumatic appliance (E0673). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee's 
physician had prescribed the use of a pneumatic compression device to prevent the formation of blood clots. 
The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. In this case, the enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device (E0676) and segmental pneumatic 
appliance (E0673).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on December 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 19, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that 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. The claim at issue was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on July 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 daily skilled services are not necessary. Our physician reviewer found the enrollee did not have any 
parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled 
care and improved; however, his functional improvement had plateaued by 3/27/22 and he did not require any 
further inpatient skilled rehab services. The enrollees function was at or near his new baseline level of function 
and he could be discharged to a lower level of care for further services. As of 3/27/22 the enrollee required 
custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 16, 2022. 
 
You asked the Plan to pre-approve SNF care after March 16, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 after March 16, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found 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 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 SNF care after March 16, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional occupational therapy sessions to be 
provided by a participating provider. 
 
You asked the Plan to pre-approve occupational therapy. You say that skilled occupational therapy services are 
required to assess wheelchair positioning for appropriate modifications/equipment in order to maximize upright posture. The Plan denied your request. The Plan says additional occupational therapy sessions 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 occupational therapy. 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 the enrollee has strong caregiver/staff support; therefore, 
additional occupational therapy is 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 occupational therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional occupational therapy sessions to be provided by a participating 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on December 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on July 20, 2021.