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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care 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 the enrollee is not medically stable, and does not need close physician supervision three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of 
chronic medical conditions. There are no rehab nursing needs identified in the records. The enrollee does not 
need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. She needs routine PT and OT and that can be safely 
provided in a skilled nursing facility (SNF) with intermittent therapies. IRF admission is not medically 
necessary based on medical stability and lack of medical complexity, and lack of rehab nursing needs. 
 
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) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee. 
 
You asked the Plan to pay for the admission. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can receive the care needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the admission. Our reviewer says that the 
requested admission is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the patient requires skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. There is no 
documentation that daily skilled services are required. The patient is walking household distances with a rolling 
walker with close supervision and is supervision/modified independent for transfers. The provided records do 
not document a significant decline in the patients functional status to necessitate daily inpatient skilled therapy 
services. There is no documentation that the patient requires the services on an inpatient basis, only in a skilled 
nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time 
basis appear appropriate 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pay for admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA 1 and 2 genetic testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary to see what other 
cancers you may have. The Plan denied your request. The Plan says this is medically necessary to see what 
other cancers you may have. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has ductal carcinoma in situ (DCIS) of the breast. The enrollee is estrogen positive, and was 
diagnosed at age 67. There is no family history of cancer. These facts do not meet the criteria for this testing, or 
the National Comprehensive Cancer Network (NCCN) criteria for testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve BRCA 1 and 2 genetic testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that the injection in December provided significant relief 
in symptoms. The Plan denied your request. The Plan says the enrollee does not meet the requirements. 
 
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 looked at the file, and Medicare rules. The enrollee last received a Synvisc injection in December 2021. A 
repeat injection may be allowed only when the last injection was given at least six months ago. Based on this 
information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Synvisc.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON home health services. You say that you have provided medical 
records to support the need for these services. The Plan denied your request. The Plan says OON care is not 
covered and network home health providers are available. 
 
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. 
 
Your organization 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 
services 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 pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON cataract surgery. You say that you have already seen this patient and 
have discussed cataract surgery with him.  You believe that having him switch to a network provider would not 
be beneficial to him.  You also said that you have submitted a request to become a network provider. The Plan 
denied your request. The Plan says cataract surgery is available from network providers. 
 
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. You are 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 cataract surgery to be provided by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 5mg Prednisone tablets. 
 
You asked the Plan to pre-approve the Prednisone. You say that you would like reconsideration because the 
Prednisone is medically necessary. The Plan denied your request. The Plan says this drug is not covered under 
Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the 5mg Prednisone tablets.  
 
Benefits for the Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF admission is not medically necessary because the patient can be managed at a 
lower level of care. 
 
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 was 
admitted for nausea, vomiting, and atrial fibrillation. Their medical problems are stable and there are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
patient has 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the L4-5 and L5-S1 
levels. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been a second set of diagnostic MBBs. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a second confirmatory medial branch block (MBB) which produces greater than 80% pain relief is 
required before RFA can be approved. Therefore, at this time, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) to the L4-5 and L5-S1 levels.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implanted spinal infusion pump (62350) for the 
enrollee. 
 You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no history of failed pain management given that surgical stabilization has been 
planned and approved, and a preliminary trial of intraspinal opioids has not been undertaken. 
 
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 pump. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has not failed oral opiate therapy, and has not had a trial of intrathecal opiates. Therefore, at 
this point, the request is 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 the pump have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an implanted spinal infusion pump (62350) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intrauterine device (IUD) placement (58300, J7296) 
provided October 26, 2021. 
 
You asked the Plan to pay for the IUD placement. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 Medicare rules also state that code 58300, insertion of IUD has an "N" status in the Medicare Physician Fee 
Schedule, which means the service cannot be covered when billed to Medicare. 
 
The procedure was billed with code 58300 which is not eligible for Medicare payment. 
 
Therefore, we decided that the Plan does not have to pay for an intrauterine device (IUD) placement (58300, 
J7296) provided October 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 You asked the Plan to pre-approve the skilled nursing facility services. You say that the SNF services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found continued services in 
the acute inpatient rehabilitation facility appear reasonable and necessary until the patient is stable to transfer to 
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 the skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology services provided on December 1, 
2020. 
 You asked the Plan to pay for the molecular pathology services. You say that you would like reconsideration 
because these codes are separate from the panel an were billed appropraiteyl. The Plan denied your request. 
The Plan says an edit exists between CPT codes 81401, 81403, 81404, 81405, 81406 and 81439. 
 
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 codes 81401, 81403, 81404, 81405 and 81406 are column II codes to 
column I code 81439; however, 81401, 81403, 81404, 81405 and 81406 was billed with a modifier.  
 
We asked our coder 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 molecular pathology services. Our reviewer says that 
CPT codes 81401, 81403, 81404, 81405 and 81406 do not meet criteria for billing or reimbursement 
consideration. Our reviewer found modifier XS cannot be verified to support that these services were rendered 
for separate structures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the molecular pathology services have not been met. Therefore, we decided that 
the Plan does not have to pay for the molecular pathology services provided on December 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (G0277, 99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the requested hyperbaric oxygen 
therapy is medically necessary. The Plan denied your request. The Plan says the requested hyperbaric oxygen 
therapy does 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 hyperbaric oxygen therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is being treated for an ulcer on the heel. The documentation 
indicates it is improving with treatment and that the enrollee is having evaluation with a vascular procedure. 
The requested service has not been shown to be superior to other standard treatments for the medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy (G0277, 99183).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say RFA is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has post-laminectomy pain 
syndrome. He had initial diagnostic facet joint injections at L3 to S1 on the left on February 9, 2022. There has 
not been a second confirmatory set of diagnostic facet injections that produced at least 80 percent pain relief. 
The criteria for RFA are not met and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses lenses (V2781, V2745) and protection plan 
(V2797) purchased on November 4, 2021. You asked the Plan to pay for the lenses and protection plan. You say that you would like reimbursement for 
these services. The Plan denied your request. The Plan says your vision benefits were applied at the time of 
purchase. Your vision benefit provides up to $100 of coverage toward the purchase and fitting of eyeglasses 
and pair of lenses or contact lenses at a network optical provider. You are responsible for any amount over the 
$100 retail price allowance. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $100 once per calendar year. 
 
We looked at the file and the Plan's rules. The documentation shows that the retail price of the eyeglasses 
purchased on November 4, 2021, was $174. After your insurance benefits were applied, you were asked to pay 
$59.20. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
In addition, the $25 charge for the protection plan is not listed as a covered service under your vision benefit. 
Therefore, we decided that the Plan does not have to provide additional reimbursement for the eyeglasses 
lenses (V2781, V2745) and protection plan (V2797) purchased on November 4, 2021.