Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve benefit coverage under the special supplemental 
benefits for the chronically ill (SSBCI) program. 
 
You asked the Plan to pre-approve benefit coverage under the SSBCI program. You say that your medical 
condition should qualify you for the benefits. The Plan denied your request. The Plan says you do not meet the 
requirements for the SSBCI program. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 benefit coverage under the special 
supplemental benefits for the chronically ill (SSBCI) program. have been met. Specifically, no medical records 
were provided for this case. The record shows that the Plan made multiple attempts to obtain medical records, 
but they were not provided. Without this information we cannot determine that this request meets the criteria 
for coverage. Therefore, we decided that the Plan does not have to pre-approve benefit coverage under the 
special supplemental benefits for the chronically ill (SSBCI) program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown on tooth #9 (D6790), retainer crowns on 
tooth #10, 13, and 15 (D6750), and pontics on tooth #11 and 12 (D6240) provided on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told what was or was not 
covered. The Plan denied your request. The Plan says retainer crowns (D6750, D6790) and pontics (D6240) are 
not covered by your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a retainer 
crown on tooth #9 (D6790), retainer crowns on tooth #10, 13, and 15 (D6750), and pontics on tooth #11 and 12 
(D6240) provided on June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Panel testing (81455) provided May 9, 2022. 
 
You asked the Plan to pay for the Tempus xT Panel testing. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed date-of-
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. The records show that the specimens were collected on April 14, 
2022. This does not match the billed date of service. Based on this information, we decided that Medicare rules 
for coverage of the Tempus xT Panel testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus xT Panel testing (81455) provided May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (CPT code E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that a shower chair is necessary. The Plan denied 
your request. The Plan says a shower chair is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (CPT code E0240).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa 75MG tablets. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Gemtesa is a self-administered drug and does not fall under Part B coverage. 
 
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 Gemtesa 75MG tablets.  
 Benefits for the medication 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee suffered a fractured femur and requires 
proper care to regain full function and mobility. The Plan denied your request. The Plan says the IRF services 
you requested do not meet the requirements for approval. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a lower 
intensity and alternate setting such as a 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 acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that transfer of the enrollee to a lower level of care such 
as a skilled nursing facility would place the enrollee at a significantly higher risk of complications, morbidity, 
re-hospitalization, and lesser degree of functional recovery. This could jeopardize the enrollees chances for a 
safe return home. The Plan denied your request. The Plan says the request is not medically necessary, the 
services the enrollee needs can be provided safely in other settings. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 6, 2021, to 
July 13, 2021. 
 
You asked the Plan to pay for inpatient services. The Plan denied your request. The Plan says it is the 
providers responsibility to bill the Primary Group Health Plan or any liability insurance before submitting the 
claim to the members Plan. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan 
cannot be held responsible for inpatient services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for inpatient services provided from  
July 6, 2021, to July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. You say that this drug is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested 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 Xarelto.  
 Benefits for Xarelto 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous skeletal fixation of femoral fracture, 
proximal end, neck (27235) provided May 25, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that the documentation supports the medical 
need for an assistant at surgery. Please review and reprocess. The Plan denied your request. The Plan says 
multiple physicians/assistants are not covered in this case. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 27235. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for the 
percutaneous skeletal fixation of femoral fracture, proximal end, neck (27235) provided May 25, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care from October 21, 
2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that you could benefit with more therapy and 
are not ready to discharge. The Plan denied your request. The Plan says that your request does not meet 
Medicare guidelines because you no longer require skilled services and the continuation of SNF is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that the requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. 
Our physician reviewer found that the Plan argues that SNF services are no longer necessary as the enrollee is 
walking 50 feet. No such records are identified in the record for review.  As such, the Plan has filed to support 
its argument. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have been met. The Plan must continue coverage for the 
SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been 
issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve 
continued skilled nursing facility (SNF) care from October 21, 2022, forward.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, shoulder; complete, minimum of 2 
views (code 73030) provided on May 30, 2022. 
 
You asked the Plan to pay for radiologic examination, shoulder; complete, minimum of 2 views. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on June 29, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for radiologic examination, shoulder; complete, minimum of 2 views have not been met. Therefore, we decided that the Plan does not have to pay for radiologic examination, 
shoulder; complete, minimum of 2 views (code 73030) provided on May 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation (RFA) 
procedure. 
 
You asked the Plan to pre-approve a lumbar facet joint RFA procedure. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet specific criteria.  
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 lumbar facet joint RFA procedure. 
Our reviewer says that [state physician reviewer's conclusion, e.g. "the service is not medically necessary." or 
"you need this medical item."] Our physician reviewer found in this case, there is no documentation the first 
diagnostic medial branch block (MBB) was completed. There are no results reported. There is, also, no 
documentation a second diagnostic MBB was completed. There is no documentation of a prior RFA procedure 
to this same region. You do not meet criteria criteria detailed in the LCD. 
 
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 lumbar facet joint RFA procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation (RFA) procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee lives on their own. You also say they 
have a needle aversion and are unable to administer injections on their own. The Plan denied your request. The 
Plan says the requested drug is not medically necessary. 
 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 Evenity. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee has tried and failed the preferred drug, Forteo. The reviewer found that there is no indication that 
the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
The Plan 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. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 29, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect date of 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. 
 
We find that payment for CPT code 81455 is not supported in the medical record. Specifically, the claim must 
be billed with the date the specimen was collected. The records show that the specimen was collected on April 
12, 2022. As such, the claim was billed with the incorrect date of service. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded as 81292, 81294, 81295, 81297, 
81298 and 81317 provided on April 15, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's physician ordered this test to help 
determine the best course of management for the enrollee's specific genetically determined scenario and 
clinical presentation. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 the genetic testing coded as 81292, 81294, 81295, 
81297, 81298 and 81317 provided on April 15, 2022 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that the enrollee requires transportation 
services due to medical conditions. The Plan denied your request. The Plan says routine transportation beyond 
24 one-way trips per year is not covered by the Plan. 
 
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 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.