Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services (G0299) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve home health skilled nursing services. You say that the requested services are 
a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for out-of-network 
care have not been met. 
 
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 
home health skilled nursing services (G0299) to be provided by an out-of-network (OON) provider.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and underwent diuresis. You were at a standby assist to contact guard assist level with functional mobility 
including gait to 250 feet. You do not require skilled nursing or therapy services on a daily basis. You do 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: 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 the enrollee requires LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care facility. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves 
using imaging guidance (64635) and destruction of lower or sacral spinal facet joint nerves with imaging 
guidance (64636). 
 
You asked the Plan to pre-approve injections. You say that the requested injections are medically necessary. 
The Plan denied your request. The Plan says the requested injections do not meet criteria. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee received 5% pain relief with his second injection. There is 
no indication of pain relief from their first injection in the medical record. The review of the medical record 
does not indicate that the enrollee had at least two medically reasonable and necessary diagnostic medial nerve 
branch blocks with each achieving the minimum required sustained 80% relief of pain per Medicare guidelines 
(LCD 33930). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve destruction of lower or sacral spinal facet joint nerves using imaging guidance (64635) and 
destruction of lower or sacral spinal facet joint nerves with imaging guidance (64636).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria 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 Truxima. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the Plan requires 
a trial of Rituxan, Ruxience, or Riabni before they will approve the requested drug. In this case, the patient 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 Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to a Long-Term Acute Care Hospital (LTACH). 
 
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 was admitted with acute respiratory failure in the setting of Guillain-
Barre Syndrome.  The record indicates that the enrollee is improving but till requires acute care services before transitioning to a 
lower level of care. The enrollee continues to receive acute care services and these have not been denied. The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips. 
 
You asked the Plan to provide additional transportation. You say that the enrollee cannot drive and does not 
have anyone who can take her to her doctor's appointments. The enrollee has multiple comorbid medical 
conditions and requires transportation. The Plan denied your request. The Plan says trips in excess of the 10 
provided by the enrollee's supplemental benefit are not covered under any circumstance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plans maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that documentation is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. In this case, there are multiple plausible pathologic sources of significant 
pain generation. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular stress test (90317), myocardial perfusion 
imaging, tomographic (SPECT) (78452) and technetium tc-99m, sestamibi, diagnostic, per study dose (A9500) 
provided on August 30, 2021. 
 
You asked the Plan to pay for a cardiovascular stress test (90317), myocardial perfusion imaging, tomographic 
(SPECT) (78452) and technetium tc-99m, sestamibi, diagnostic, per study dose (A9500). The Plan denied your 
request. The Plan says these 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 pay for a cardiovascular stress test (90317), 
myocardial perfusion imaging, tomographic (SPECT) (78452) and technetium tc-99m, sestamibi, diagnostic, 
per study dose (A9500). Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee had a history of a bicycle accident in May 
of 2021 with contusion and elevated troponin. By August of 2021 she was feeling clinically well. There is no 
evidence provided that would support the need for radionuclide stress testing. In summary, there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing 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 a cardiovascular stress test (90317), myocardial perfusion imaging, tomographic 
(SPECT) (78452) and technetium tc-99m, sestamibi, diagnostic, per study dose (A9500) have not been met. 
Therefore, we decided that the Plan does not have to pay for a cardiovascular stress test (90317), myocardial 
perfusion imaging, tomographic (SPECT) (78452) and technetium tc-99m, sestamibi, diagnostic, per study 
dose (A9500) provided on August 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says you 
have used 50 trips and exhausted your transportation benefit. The Plan also says that more than 50 one-way 
trips per plan year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 50 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested service is experimental/investigational. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that 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 device would not be considered medically appropriate and necessary 
in the enrollee's 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a CardioMEMS device (33289).
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 enrollee requires IRF care. 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 the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 29, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the service. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 29, 2021 have been met. The records provided to the Health Plan are undated, and unsigned. There 
is insufficient documentation of physical exam, pain scale, and response to prior injections. Therefore, we 
decided that the Plan does not have to pay for an epidural injection provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care services provided on June 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for OON vision care. You say that these services were medically necessary. The 
Plan denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. 
The services in this case were not urgent or emergent, nor were they pre-approved. 
 
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 vision care services provided on June 22, 2021, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 1, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical records only support 15 drug classes. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation that support that 22 or more drug 
classes were tested in this case. The provided records document less than 22 distinct drug classes were tested 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on December 1, 2020.