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

 
We decided that the Plan does not have to pay for lab services provided on September 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that you did not have a contract with the dialysis 
facility, so these lab services should be paid. The Plan denied your request. The Plan says no separate payment 
is made for these lab services. 
 
The Plan must follow Medicare rules. Medicare rules say that all end-stage renal disease (ESRD)-related 
laboratory services are included in the ESRD Prospective Payment System (PPS) base rate and must be 
reported by the ESRD facility and are not separately paid. The lab services in question were provided to an 
ESRD patient, so payment for these lab services is included in the ESRD PPS rate. 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 lab services provided on September 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower extremity study (93925) provided on October 5, 
2021. 
 You asked the Plan to pay for the lower extremity study. You say that this service is supported in the records. 
The Plan denied your request. The Plan says the diagnosis code provided does not support the medical 
necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that providers must report services correctly.  
 
In this case, we find that CPT code 93925 is not supported in the medical record. Specifically, the diagnosis 
code billed on this claim is not included on the list of appropriate diagnosis codes to support the medical 
necessity of CPT code 93925. Based on this information, we decided that Medicare rules for coverage of the 
lower extremity study have not been met. Therefore, we decided that the Plan does not have to pay for the 
lower extremity study (93925) provided on October 5, 2021.
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 do not have documented skilled nursing 
need or documented skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full urinary tract infection panel coded as 87481, 87491, 
87529, 87556, 87591, 87640, and 87798 provided July 29, 2021. 
 
You asked the Plan to pay for full urinary tract infection panel. You say that you request reconsideration of the 
denial and payment in full for the testing. The Plan denied your request. The Plan says the service does not 
meet Medicare rules as reasonable and 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 full urinary tract infection panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that the enrollee with urinary tract infection and 
presenting for rapid COVID testing. Urinalysis showed protein and blood. The review indicates that the Infectious Disease Society of America and Healthcare Infection Control Practices Advisory Committee 
(HICPAC), state standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a 
urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large 
multiplex PCR urinary tract infection panel tests. The request for specific infectious agents by nucleic acid 
amplification exceeds the enrollees medical needs. Also, outpatient point- of-care antibiotic resistance testing 
by PCR is particularly limited by: the diversity of antibiotic resistance mechanisms present in general practice; 
a lack of epidemiological information on the origin and spread of antibiotic resistance mechanisms within 
particular geographical locations and within particular communities; and limitations on currently available 
POC diagnostic technologies to rapidly detect the many different types of antibiotic resistance mechanisms 
known. The review indicates that the items/services at issue in this case are 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 full urinary tract infection panel have not been met. Therefore, we decided that 
the Plan does not have to pay for full urinary tract infection panel coded as 87481, 87491, 87529, 87556, 
87591, 87640, and 87798 provided July 29, 2021.
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. The Plan denied your request. The Plan says you are at home and 
stable. 
 
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 physician reviewer found 
that you have a new diagnosis of Parkinson's disease and is living at home with problems with weakness and 
balance. Medical problems are stable. 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. 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 the services provided on October 25, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that PTA services cannot be billed incident to NPP 
services as the NPP is not considered a therapist.  
 
The NPP is billing for the services of the PTA, which is not allowed per the cited rules. Therefore, we decided 
that the Plan does not have to pay for the services provided on October 25, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be somewhat unstable and requires short-term additional acute 
care hospital services that can be safely completed at the current facility until treatment is completed and the 
patient is appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary 
as the enrollee is unstable and as it would not be clinically advantageous at this time. 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sarclisa in combination with Velcade and 
Dexamethasone. 
 
 
You asked the Plan to pre-approve the drug combination. The Plan denied your request. The Plan says the 
clinical effectiveness for the combination has not been demonstrated for multiple myeloma. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Sarclisa. Our physician reviewer found 
that the drug combination is not FDA-approved for the enrollee's diagnosis. There is FDA approval in 
combination with Pomalidomide and Dexamethasone after 2 prior lines of therapy including Lenalidomide and 
a proteosome inhibitor or with Carfilzomib and Dexamethasone after 1-3 prior lines of therapy.  
 The requested use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in 
any of the compendia. The documentation does not support that the requested drug is safe and effective and 
otherwise reasonable and necessary for this 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 Sarclisa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Sarclisa in combination with Velcade and Dexamethasone.
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 records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. Although you are very 
limited functionally, provided records do not document a significant decline in your functional status compared 
to your recent baseline to necessitate daily inpatient skilled therapy services. You do not require the services on 
an inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the long-
term care facility on a part time basis are not 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the enrollee's hemoglobin is 7.3. The Plan denied your 
request. The Plan says the enrollee has not tried and failed Aranesp or Retacrit. 
 
 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 Procrit. Our physician reviewer found 
that the enrollee has a diagnosis of anemia in neoplastic disease. The Plan requires a trial of Aranesp or Retacrit 
before they will approve the requested drug. The case file does not contain documentation of trial and failure of 
the required drugs. The documentation does not support that Aranesp or Retacrit would likely be less effective 
or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
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 epidural steroid injections. You say that you had your first injection, but 
your provider feels that you need additional injections as they are trying to decrease your inflammation so that 
you will not require back surgery at this time and to improve your quality of life. The Plan denied your request. 
The Plan says that you do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale for at least three months. 
 
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 epidural steroid injections. Our 
reviewer says that a repeat epidural steroid injection (ESI) is not medically necessary. Our physician reviewer 
found that you have not had the previous ESI three months or longer before a repeat ESI, with the first injection 
directly and significantly providing improvement of the condition being treated by at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using SAME scale for at 
least three months.  The review has determined that the requested repeat epidural steroid injection does not meet the Medicare LCD 
coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
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 meets the full IRF criteria for coverage. 
You say that the enrollee requires intensive inpatient rehabilitation with daily physician management, 24-hour 
specialized rehabilitation nursing, and intensive therapies to optimize mobility and strengthening while 
ensuring the restoration of functional status for a safe and sustainable discharge. The Plan denied your request. 
The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can 
safely receive the services needed 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has 
a past medical history of diabetes, congestive heart failure, atrial fibrillation, dementia, and chronic obstructive 
pulmonary disease. The enrollee is living at home with balance problems and weakness. He is receiving home 
health services for a leg wound and home health physical therapy services. The enrollee's medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the enrollee 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 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: 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 these services are medically necessary. 
The Plan denied your request. The Plan says that your records do not show that you need treatments that can 
only be given in a hospital setting or that your condition will require an average of 25 days in the 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. You appear 
to be improving and should only require short-term additional acute care hospital services that can be safely 
completed at the current facility until appropriate for a lower level of care. You do not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that you 
require that are not already available and covered at the current facility. Our physician reviewer found that your 
condition does not meet Medicare criteria for LTACH 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 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 endovascular services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that failure to undergo therapy would result in 
inadequate treatment. The Plan denied your request. The Plan says there is no network deficiency. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
endovascular services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010), a 
tooth extraction (D7210) and an alveoloplasty in conjunction with extractions (D7310, D7311). 
 
You asked the Plan to pre-approve dental procedures. You say that some of these procedures should be covered 
under medical because of the anesthesia and the surgical side of each item. The Plan denied your request. The 
Plan says your plan covers items and services in accordance with Medicare rules. While screws placed in your 
bone to hold a false tooth (crown or denture) may be appropriate in this case, neither Medicare nor your plan 
covers these items. 
 
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 pre-approve a 
surgical placement of an implant body (D6010), a tooth extraction (D7210) and an alveoloplasty in conjunction 
with extractions (D7310, D7311).