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

 
We decided that the Plan does not have to pay for genetic prostate testing (81542) billed for date of service 
April 13, 2022. 
 
You asked the Plan to pay for genetic testing services. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this test was not billed in 
accordance with Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic prostate testing (81542) billed for date of 
service April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injections (64483 and 64484). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the enrollee's pain level is 8 out 
of 10. The Plan denied your request. The Plan says the repeat injections are not reasonable and medically 
necessary. 
 
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 epidural steroid injections. Our 
physician reviewer found there is no documentation provided indicating that the previous epidural steroid 
injection provided at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using same scale for at least 3 months. The review has determined that the 
requirements listed in the LCD for Medicare coverage 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 the epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the epidural steroid injections (64483 and 64484).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 enrollees nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 
hours over seven consecutive days. Therefore, the acute inpatient rehabilitation admission is not 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection You asked the Plan to pre-approve the requested services. You say that you cannot walk due to the pain. The 
Plan denied your request. The Plan says you do not meet the Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records show that the previous injection only provided 2 days of 
pain relief. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says the enrollee has not 
tried anticholinergic medications. 
 
 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 Botox. Our physician reviewer found 
that the enrollee has a diagnosis of overactive bladder. The Plan requires a trial of two anticholinergic 
medications, such as Ditropan, Detrol, Vesicare, Enablex, Toviaz, Sanctura, or Oxytrol before they will 
approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no 
documentation indicating that the Plans required drugs would likely be less effective or likely have adverse 
effects for the 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you think that the LTACH services is the 
best level of care for the enrollee's medical needs. The Plan denied your request. The Plan says the records do 
not show that the enrollee has a condition that would require at least 25 days or more of additional care at an 
LTACH. The enrollee will need continued care. The enrollee can safely receive this care in another setting, 
such as a hospital setting. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multiple services (92014, 92201, 92134, 3044F) provided on 
May 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for multiple services (92014, 92201, 92134, 3044F). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network and authorization is required prior to an out-of-network visit. 
 
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 multiple services (92014, 92201, 92134, 3044F) 
provided on May 31, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you need a lift chair because the blood is 
down to your knees and you need to have your feet elevated, above your heart level. You are in a lot of pain. 
The Plan denied your request. The Plan says you do not meet criteria for approval of a seat lift. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found you do not have severe arthritis 
of the hip or neuromuscular disease. The records do not show that a seat lift is included in the treating 
practitioner's course of treatment. The records do not show that you are completely incapable of standing from 
a chair in the home. You can ambulate with limited mobility. 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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3 platelet rich plasma (PRP) injections provided on April 
14, 2022. 
 
You asked the Plan to pay for the PRP injections. You say that the PRP injections are a more cost-effective 
option than shoulder replacement surgery. You say that you are concerned about having surgery at your age. 
You also say that you are in a lot of pain caused by your arthritis. The Plan denied your request. The Plan says 
the injections were not medically 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 the PRP injections. Our reviewer says that 
the PRP injections are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an 
effective and/or safe treatment for the noted pathology. The reviewer found that further studies are needed to 
support that platelet-rich plasma injections are safe and effective for shoulder osteoarthritis. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the reviewer found that the platelet-rich plasma (PRP) injections were 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 PRP injections have not been met. Therefore, we decided that the Plan does 
not have to pay for the 3 platelet rich plasma (PRP) injections provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on March 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo 6MG/0.05ML solution (CPT code J3490). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee does not have any stated contraindications to the preferred products. 
The Plan states the enrollee has not tried any of the preferred agents and the provider does not provide a 
rationale for use of the non-preferred product for safety or efficacy and you do not have any stated contraindications to the preferred products. The Plan states you have not tried any of the preferred agents and 
the provider does not provide a rationale for use of the non-preferred product for safety or efficacy. 
 
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 the medication. Our physician reviewer 
found there is no indication that you have tried and failed the required drug(s).  Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vabysmo 6MG/0.05ML solution (CPT code J3490).
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 admission to the LTACH is medically 
necessary. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital at this 
time because they do not meet the criteria for stability. There was an acute change in the enrollee's neurostatus. 
The enrollee is receiving the care they need in the hospital where they are now and there is no need to transfer 
to the LTACH at this time. The enrollee can stay in the hospital until they are safe for transfer or discharge. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you want the Plan to pay for the services. 
The Plan denied your request. The Plan says services were received from an ineligible provider. 
 
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 laboratory services provided on 
have been met. The provider did not send records to support that the testing was performed, or that show the 
pathologist is eligible to be paid. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on July 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapy visits (G0151 x9). 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident 
need for the services of a skilled physical therapist. The Plan states you have already been educated on a home 
exercise program and there is no documentation of an active or acute on chronic condition that would 
necessitate a new program. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy visits. 
Our physician reviewer found the documentation does not support that you require additional skilled 
rehabilitation services to provide treatment that is 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 the home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health physical therapy visits (G0151 x9).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the inpatient behavioral health admission to a state hospital. 
 
You asked the Plan to pre-approve the inpatient psychiatric services. You say that the admission and care 
should be approved. The Plan denied your request. The Plan says that long-term state hospitalization is not 
covered by the plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not include documentation to support the why the 
services are needed, nor why they were denied. Therefore, we decided that the Plan has to pre-approve the 
inpatient behavioral health admission to a state hospital.  
 
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.