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

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission to be 
provided by a network provider. 
 
You asked the Plan to pre-approve the SNF admission. You say that the SNF admission is medically necessary. 
The Plan denied your request. The Plan says authorization denied because the SNF admission is not medically 
necessary, and the enrollee is receiving adequate and necessary intensive rehabilitation in the inpatient 
rehabilitation facility.  
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled 
nursing service needs that require skilled nursing services, including the specialized skill, knowledge and 
judgment of a skilled professional nurse required to safely and effectively provide medically necessary and 
reasonable treatment. There are identifiable skilled therapy service needs that require skilled therapy services, 
including the specialized skill, knowledge and judgment of a qualified therapist required to safely and 
effectively provide medically necessary and reasonable treatment. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. As a practical matter, this patient does not meet severity of illness 
or intensity of service criteria required for admission on 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission to be provided by a network 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services provided on October 12, 
2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that you were not aware there would 
be an extra charge on top of the copayment for the visit. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for diagnostic lab services and diagnostic procedures and tests.  
 
 You have been asked to pay a $3.48 copayment for the lab services, which is less than the $10 copay. The lab 
services fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the lab services provided on October 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour lancets and test strips. 
 
You asked the Plan to pre-approve Contour lancets and test strips. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says the review has shown that you have 
gotten approved and are using the Dexcom G6 Continuous Glucose Monitor (CGM) system and the Libre 
CGM system, both of which are similar CGM systems that do not require finger sticks to track your blood 
sugar. The Plan says they called and confirmed with you that you still have and are using both of these systems 
to follow your blood sugars without sticking your finger. The Plan says they cannot approve the request for 
Contour lancets and test strips as your doctor has not explained and documented why you would still need the 
Contour lancets and test strips to check your blood sugar by sticking your finger in addition to the Dexcom G6 
and Libre Freestyle systems. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The file shows that you are using a Dexcom G6 CGM and a Libre 
CGM system in place of a blood glucose monitor where you stick your finger to track your blood sugar. The 
documentation provided does not show why it would be medically necessary for you to continue using lancets 
and test strips to stick your finger to track your blood sugar when you are using a CGM system where you do 
not have to stick your finger to test your blood sugar. Based on this information, we decided that Medicare 
rules for coverage of Contour lancets and test strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Contour lancets and test strips.
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 you feel that this level of care is necessary. The Plan 
denied your request. The Plan says the Medicare rules for IRF services have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
related supplies 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM) and related supplies
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESI) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that a repeat ESI at the same anatomical site is reasonable or necessary 
at this time. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The enrollee has 
chronic low back pain, spinal stenosis, facet hypertrophy, bilateral neural foraminal stenosis, and leg pain. The 
enrollee's pain is severe, and she is unable to ambulate without assistance. She is treated with medical therapy 
and underwent transforaminal epidural steroid injections (TFESI) bilateral L4-L5 and L5-S1 levels on 
September 29, 2021. She reported pain relief which lasted for only three and a half weeks. You have 
recommended repeat TFESI's at the same anatomical site (bilateral L4-L5 and L5-S1 levels) as the first 
injections. Pain relief from the ESI's only provided pain relief for a period of 3 weeks. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections (ESI) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthoscopic rotator cuff repair with balloon 
procedure. 
 
You asked the Plan to pre-approve the arthoscopic rotator cuff repair with balloon procedure. You say that this 
procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure is 
considered investigational and not considered standard of care for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the arthoscopic rotator cuff repair with 
balloon procedure. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the balloon procedure remains experimental for 
rotator cuff pathology. More research is needed to show safety and efficacy. 
 
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 arthoscopic rotator cuff repair with balloon procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the arthoscopic rotator cuff repair with 
balloon procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested procedure is considered 
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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed. 
 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
related supplies. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that a therapeutic CMG is medically 
reasonable and necessary for your condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM) and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve the requested services. You say that the pain is unbearable. The Plan denied 
your request. The Plan says coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that you have chronic low back pain with lumbar radiculopathy. On February 16, 2021, you had 
a transforaminal epidural steroid injection (TFESI) which provided 30% pain relief for 2 weeks. On May 11, 
2021, you had a TFESI at L3-L4 provided 40% relief. A repeat ESI is covered when the first injection provides 
at least 50% of sustained improvement in pain relief and/or improvement in function for at least three months. 
The records do not show that the coverage criteria have been met for the requested injections. Therefore, the 
requested injections are not considered medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve epidural steroid injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan for the enrollee. 
 
You asked the Plan to pre-approve Hyalgan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred agents would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Hyalgan. Our reviewer says that 
Hyalgan is not medically reasonable and necessary for the enrollee. The Plan requires a trial of Orthovisc or 
Supartz FX 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 the Plan's required drugs would likely 
be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Hyalgan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasound (76857) provided on November 29, 2021. 
 
You asked the Plan to pay for code 76857. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 76857 is a column II code to column I code 76775. 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 (76857) 
provided on November 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasound (76705) provided on December 7, 2021. 
 
You asked the Plan to pay for code 76705. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. 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 (76705) provided on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal test provided on November 10, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test is designed to inform the enrollee in 
advance of radiographic detection. The Plan denied your request. The Plan says there is no indication that 
tissue-based genetic testing cannot be performed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The records show that the test at issue is a monitoring test for the detection 
of circulating tumor DNA. Medicare does not cover this testing for screening purposes. Therefore, we decided 
that the Plan does not have to pay for the Guardant Reveal test provided on November 10, 2021.