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

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve sclerotherapy. You say that you have been getting these injections due to 
nerve damage from surgery. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because the treatment of spider veins or superficial telangiectasis by any technique is 
considered cosmetic and non-covered. 
 
The Plan follows Medicare rules. Medicare rules state that sclerotherapy is only covered if certain criteria are 
met, and treatment of spider veins or superficial telangiectasis is considered cosmetic and therefore non-
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 sclerotherapy. Our reviewer says that 
you do not meet the Medicare criteria for the requested sclerotherapy. Our physician reviewer found the 
treatment of spider veins or superficial telangiectasis by any technique is considered cosmetic and therefore is 
not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the member has not 
tried and failed the preferred step therapy Orthovisc or Supartz FX. 
 
  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 Euflexxa. Our reviewer says that the 
elements of the coverage criteria are not satisfied, the requested service cannot be recommended. Our physician 
reviewer found that the provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would 
have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
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 facility you would like to go to provides a 3 hour 
long inpatient therapy that you need to get your health and strength back. The Plan denied your request. The 
Plan says the IRF services you and/or your provider are requesting 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 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. Our reviewer 
found that 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. Our 
physician reviewer also found that 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: 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 strongly that the Plan should reconsider 
their original admission denial and grant authorization for the enrollee to be admitted to the IRF. The Plan 
denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting 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. Our reviewer 
found that 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. Our 
physician reviewer also found that 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee qualifies for SNF care and these 
services are medically necessary. The Plan denied your request. The Plan says the criteria for admission to an 
SNF are not met. The services the enrollee requires can safely be received in an alternate 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services that require the specialized skill, knowledge and judgement of a skilled professional nurse to safely 
and effectively provide medically necessary and reasonable treatment. The enrollee does require skilled therapy 
services which require the specialized skill, knowledge and judgement of a qualified therapies, but the 
documentation does not support that it is medically reasonable and necessary to provide these skilled services 
on a daily basis in an inpatient, skilled nursing facility setting. The enrollee's care needs can be met in an 
alternate setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered on July 7, 2021 to July 
12, 2021. 
 
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 must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services 
were rendered.  
 Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered 
on July 7, 2021 to July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided on May 5, 2021. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct 
POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus Gene Panel have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the Tempus Gene Panel provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that you were not noted to be at risk of 
harming yourself or others, nor is there documentation of severe enough dysfunction that could not be 
addressed at the outpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you would improve in a reasonable period of time as you do not have dangerousness to self or 
others and are not showing any auditory/visual hallucinations or any aggressive behaviors. It does not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care as you do not have dangerousness to self or others. Our physician reviewer found that 
your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services (86077) provided on 
October 26, 2021. 
 You asked the Plan to pay for the blood bank physician services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this claim exceeds the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blood 
bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for the 
blood bank physician services (86077) provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis 
vaccine (Tdap) shot provided on November 10, 2021. 
 
You asked the Plan to pay for the TDAP shot under Medicare Part B. You say that this shot should be covered 
by the Plan. The Plan denied your request. The Plan says this type of immunization is not covered under 
Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP shot 
under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or 
directly exposed to any illness related to the TDAP shot under Medicare Part B. Payment for this vaccine 
should be submitted to Medicare Part D. Therefore, we decided that the Plan does not have to pay for the 
Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) shot provided on November 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozurdex. 
 
You asked the Plan to pre-approve Ozurdex. You say that the patient was diagnosed with retinal edema and 
Ozurdex was ordered to decrease the edema and stabilize the vision. You say that medical records show past 
treatment was unsuccessful and this treatment should be approved. The Plan denied your request. The Plan says 
the off-label use of this drug for your condition is not medically accepted per Medicare rules and isn't covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Ozurdex. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated 
for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ozurdex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ozurdex.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel rendered on November 9, 2021. 
 
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 must follow Medicare rules. Medicare rules say that respiratory panels with six or more pathogens 
tested are not covered. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that six pathogens were tested. Therefore, we decided 
that the Plan does not have to pay for the respiratory panel rendered on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft (20930), autograft (20936), arthrodesis (22633, 
22634) and posterior segmentation (22842). 
 
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 your records do not show you have had x-rays and advanced 
imaging within the past 6 months that shows that you have moderate to severe disc breakdown to one level of 
your spine in your low back. 
 
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. Detailed 
documentation is not evident regarding dynamic flexion/extension films that demonstrate movement 
(instability) at the requested surgical level. Detailed documentation is not evident regarding potential 
impending/inevitable temporary intra-operative instability. The April 16, 2018 x-rays of the lumbar spine have 
conclusions of multiple level spondylosis degenerative changes, and no lumbar spine vertebral body 
compression loss of height. There are no updated x-rays provided.  The April 1, 2022 MRI of the lumbar spine demonstrate L4-5: circumferential disc bulge with facet and 
ligamentum flavum hypertrophy, moderate spinal canal stenosis, no significant foraminal stenosis, these 
findings have progressed since the prior exam; L5-S1: severe left and mild right facet arthrosis with trace disc 
bulge, severe left neural foraminal stenosis, spinal canal, and right neural foramen are patent, these findings 
have progressed since the prior exam. Spondylolisthesis is not demonstrated in the imaging studies. The 
requested lumbar fusion would not typically be fully indicated for this clinical scenario. Our physician reviewer 
found that your 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 allograft (20930), autograft (20936), arthrodesis (22633, 22634) and posterior 
segmentation (22842).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on January 6, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this denied 
as a duplicate in error. The Plan denied your request. The Plan says the submitted documentation supports 1 
(one) unit of 71045-26, which was previously approved/paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the chest x-ray (71045) provided on 
January 6, 2021. have been met. Specifically, the documentation submitted supports 1 unit of CPT code 71045. The record shows the Plan paid for one unit of CPT code 71045 and there is no documentation to support that 
an additional unit was rendered on the billed date of service. Therefore, we decided that the Plan does not have 
to pay for the chest x-ray (71045) provided on January 6, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided 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.  The enrollee is medically stable, living at home and does not need physical medicine and rehabilitation 
physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. 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. At the current functional level, the enrollee's rehab can be safely provided at a lower intensity and 
alternate setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on December 9, 2021. 
 
You asked the Plan to pay for the dental service. You say that you feel this service should be covered. The Plan 
denied your request. The Plan says the periapical x-ray is not listed as a covered service. 
 
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 periapical x-ray is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray 
(D0220) provided on December 9, 2021.