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

 
We decided that the Plan does not have to pre-approve Synvisc for the enrollee. 
 
You asked the Plan to pre-approve Synvisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred agents would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Synvisc. Our reviewer says that 
Synvisc is not medically reasonable and necessary. The enrollee has not trialed one viscosupplemental 
treatment such as Orthovisc or Supartz FX. Step therapy, as outlined by the Plan, requires that one of these be 
trialed first. The documentation does not outline contraindications or reasons these medications were not 
considered. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for 
Synvisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G device. 
 
You asked the Plan to pre-approve the MyoPro Motion G device. You say that this device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested device is 
considered experimental/investigational at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro device is not known to be effective, based on scientific 
evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The 
MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature 
that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm 
function, or be safe for long term use. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 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 MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MyoPro Motion G device.
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 is a great IRF candidate. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 that 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.  Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve the OT visits. You say that the enrollee's son and daughter in law are 
concerned for the enrollee's safety in activities of daily living. The Plan denied your request. The Plan says the 
documentation from the OT evaluation does not indicate that the enrollee requires a skilled therapist to assist 
them in the home and the enrollee's needs can be met by their caregiver. 
 
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 OT visits. Our reviewer says that 
the requested home health services are not medically necessary. Our physician reviewer found the 
documentation does not support that the member requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. Our reviewer found that the member does not require additional skilled 
rehab services to effectively provide treatment, care, and/or services in order to improve the members 
condition, perform a maintenance program to maintain the members condition and/or prevent deterioration. 
Our physician reviewer also found that the member has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. 
 
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 OT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 4 occupational therapy (OT) visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Long-Term Care in a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve Long-Term Care in a SNF. You say that you believe the enrollee meets the 
criteria of "skilled services" as defined in the Medicare Benefit Manual. The Plan denied your request. The 
Plan says Medicare does not pay for custodial care under any condition. 
 
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 Long-Term Care in a SNF. Our 
reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found 
the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of Long-Term Care in a SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Long-Term Care in a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 29, 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 were not billed correctly. 
 
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 these services 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 laboratory services rendered on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and an electronic 
connection. 
 
You asked the Plan to pre-approve an expandable controller, harness, and an electronic connection. 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 power wheelchair accessories are covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller, harness, and 
an electronic connection. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the expandable controller (E2377), expandable controller harness (E2313), and electronic 
connect (E2311) and other types of proportional input devices (e.g., mini-proportional or compact joysticks, 
touchpads, chin control, head control, etc.) are not medically necessary per Local Coverage Article: Wheelchair 
Options/Accessories - Policy Article (A52504). You do not require non-proportional input devices (e.g., sip 
and puff, head array, etc.). You do not require a separate display (i.e., for alternate control devices), other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. You have 3 power options of tilt, recline, and power elevating leg rests but 
you do not need to control the power options through a joystick. Your upper extremity strength supports that 
you can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness, and an electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, and 
an electronic connection.
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 this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee can safely receive the services she needs 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for syncope and a seizure. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not covered for your condition. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. You have a diagnosis of COPD. There is 
no documentation of CO2 retention on an arterial blood gas done while stable as an outpatient. You do not 
qualify for a respiratory assist device. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. Our physician reviewer found that your condition does not meet Medicare criteria for a portable 
ventilator.  
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services provided on October 19, 2021. 
 
You asked the Plan to pay for emergency room services. You say that that you had pain on the right side of 
your lower back, and you were concerned due to a previous Hodgkin (B-Cell) Lymphoma diagnosis. You say 
that you could not see your primary physician for a number of weeks and felt that your only option was to be 
seen in an emergency facility. The Plan denied your request. The Plan says that to receive payment for covered 
Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary 
(in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. 
 
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. Medicare rules say the opt-out rule is only applicable to providers that are considered physicians by 
Medicare rules. Facilities or labs are not subject to opting out of Medicare. 
 
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 Plan has not provided proof that this provider is considered a 
free-standing emergency department. Therefore, we decided that the Plan has to pay for emergency room 
services provided on October 19, 2021.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dry needling (20560 x8). 
 
You asked the Plan to pre-approve the dry needling. You say that your doctor and physical therapist 
recommended this procedure. The Plan denied your request. The Plan says this request is not reasonable or 
necessary at this time. The Plan also says that you are not restricted from receiving the service, only that the 
service will not be covered by your Medicare plan. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, it appears this treatment is being requested for an 
ankle strain/ankle pain. You are not going to be receiving this treatment for chronic low back pain. Therefore, 
we decided that the Plan does not have to pre-approve dry needling (20560 x8).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on April 7, 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 if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code.  Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on April 7, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a SNF admission. The Plan denied your request. The Plan says the enrollee 
needs skilled nursing and would benefit from it. You also say that you think the enrollee would be able to retain 
what he learns from physical therapy. 
 
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 a SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (88341, 88342) provided on October 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 88341 and 88342 are column II codes to column I code 88360. This 
claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (88341, 88342) provided on October 4, 2021.