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

We decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 genetic testing (81162) with 
molecular pathology procedures (81405, 81406). 
 
You asked the Plan to pre-approve BRCA 1 and BRCA 2 testing. You say that the enrollee was diagnosed with 
prostate cancer with a Gleason score of 7, and this testing is medically necessary to determine the enrollee's 
future course of treatment. The Plan denied your request. The Plan says the requested BRCA 1 and BRCA 2 
genetic testing is not medically necessary, and the enrollee does not meet the criteria for coverage. 
 
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 BRCA 1 and BRCA 2 testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has a Gleason score of 7 and a Prostate-Specific Antigen 
(PSA) of 6. Based on the documentation provided, the enrollee is not high or very high risk according to the 
National Comprehensive Cancer Network (NCCN) criteria. The necessary criteria are not met 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 BRCA 1 and BRCA 2 testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve BRCA 1 and BRCA 2 genetic testing (81162) with molecular pathology 
procedures (81405, 81406).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the consultation. You say that you have heard good things about this out-of-network doctor. The Plan denied your request. The Plan says the provider is out-of-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider
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 transfer to an IRF is medically necessary for this 
enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The 
enrollee's continued care can be provided in an alternate setting. 
 
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 the enrollee's nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the documentation does support a need for physical and/or occupational therapy, there is no documented need 
for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 
enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.
You asked the Plan to pre-approve out of network physician services. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not in network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 out of network physician services. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found according to Medicare a service is medically reasonable and necessary if it is safe and effective and not mainly for the convenience of the patient or the physician. In order to be considered medically necessary a service cannot be investigational or experimental and must be ordered by qualified personnel and be appropriate to the patient's medical needs and condition. Additionally, there must be an appropriate duration and frequency that is considered appropriate for the service.
In this case, the records show you have had some post-operative complications including poor wound healing. The documentation indicates that you were instructed to take antibiotics and whirlpool treatments and a wound specialist consultation should be obtained. There is no indication that you are unable to obtain the treatment recommended from an in-network provider. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out of network physician services have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve out of network physician services. Therefore, we decided that the Plan does not have to pre-approve out of network physician services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve VIA Disc Allograft procedure.
You asked the Plan to pre-approve VIA Disc Allograft procedure. You say that the requested VIA Disc
Allograft procedure is medically necessary. The Plan denied your request. The Plan says the requested VIA
Disc Allograft procedure 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 VIA Disc Allograft procedure. Our
reviewer says that the requested VIA Disc Allograft procedure is not medically necessary. Our physician
reviewer found this is an experimental/investigational procedure. Therefore, the request is deemed 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 VIA Disc Allograft procedure have not been met. Therefore, we decided that
the Plan does not have to pre-approve VIA Disc Allograft procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided between April 1, 2021, to May
12, 2021.
You asked the Plan to pay for the medical services. You say that you would like to be reimbursed for these
services. The Plan denied your request. The Plan says documentation required to process these claims is
missing.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. In this case, the required information detailing the medical services
provided and the itemized billing of the services provided were not provided. Based on this information, we
decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that
the Plan does not have to pay for the medical services provided between April 1, 2021, to May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation procedure
provided on January 20, 2021.
You asked the Plan to pay for the genicular nerve radiofrequency ablation procedure. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were
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 pay for the genicular nerve radiofrequency ablation
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee was experiencing worsening knee pain, at
times incapacitating. The enrollee's current medications have provided insufficient pain relief. Genicular nerve
blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary
for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint
disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee
replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. Therefore,
the enrollee did not meet criteria for the services rendered.
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 genicular nerve radiofrequency ablation procedure have not been met.
Therefore, we decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation
procedure provided on January 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the physical therapy. You say that you do not want to continue to see the in-network provider. The Plan denied your request. The Plan says the provider is out-of-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services coded as 99601 and 99602
provided on March 18, 2021.
You asked the Plan to pay for the home infusion services. You say that you would like these claims
reprocessed based on the medical documentation. The Plan denied your request. The Plan says these claims are
not payable per Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 99601 are 99602 is not eligible for payment. Specifically, these claims both have a
status indicator of "I," indicating that they are not valid for payment under Medicare rules. Based on this
information, we decided that Medicare rules for coverage of the home infusion services have not been met.
Therefore, we decided that the Plan does not have to pay for the home infusion services coded as 99601 and
99602 provided on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the tubing extension set (S1015) and infection control
supplies (S8301).
You asked the Plan to pay for the tubing extension set and infection control supplies. You say that you would
like these claims reprocessed for payment. The Plan denied your request. The Plan says these claims are not
valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes S1015 and S8301 are not eligible for payment according to Medicare rules.
Specifically, these codes both have a status indicator of "I" which indicates they are not eligible for payment
under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tubing
extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not
have to pay for the tubing extension set (S1015) and infection control supplies (S8301).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded as 76705 provided on July 1, 2021.
You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says an appropriate modifier was not billed with this service.
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 76705
is a column II code to column I code 93976. 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 ultrasound services coded as 76705 provided on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that the requested CGM is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that the enrollee does not meet criteria. Our physician reviewer found in this case, the record indicates that the enrollee has diabetes and is on insulin. The record does not indicate that the insulin dose requires frequent adjustment by the beneficiary based on testing results. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be received in another setting.
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 are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care, such as skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature. You say that this will help you get in and out of bed. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Orthovisc. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the left knee. The documentation does not support that the enrollee has tried and failed Euflexxa, Supartz Fx, Durolane, or Gelsyn-3. The documentation does not support that the Plan's required drugs would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care to be provided to the enrollee by an out-of-network provider.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says there are in-network providers that can provide the services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve SNF care to be provided to the enrollee by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.

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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found based on the documentation
provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented
skilled therapy needs. The enrollee appears unable to participate in daily skilled therapy. Daily skilled services
are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).