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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you have severe back pain and that it 
is affecting the way you walk. The Plan denied your request. The Plan says medical studies have not shown 
that the requested procedure is helpful for the treatment of the enrollee's health problem. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from June 3, 2021, to June 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. The initial documentation of 
the member's functional status regarding eating, oral care and toilet hygiene was not correct. The 1st and 3rd 
alphanumeric character in the PDPM was correct.  The partial adjustment to PDPM GEPE1 was appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. 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 skilled nursing facility (SNF) services provided to the enrollee from June 3, 2021, to June 30, 
2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Lupron Depot. 
 
You asked the Plan to pre-approve Lupron Depot. You say that you are appealing with records. The Plan 
denied your request. The Plan says the Plan requires a trial of Eligard before it will approve Lupron Depot. 
 
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 Lupron Depot. Our reviewer says that 
the enrollee does not meet criteria for a step therapy exception for Lupron Depot. Our physician reviewer found 
the enrollee has not tried and failed the Plan's preferred drug of Eligard. The record does not show that this 
drug would likely be less effective and/or 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 Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of Lupron Depot.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 22,2021, through 
July 29, 2022, and billed with diagnosis code A41.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.9 (Sepsis, unspecified 
organism). 
. 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the documentation does not support the primary diagnosis of A41.9, 
Sepsis. Our physician reviewer found the documentation does not consistently and completely support the 
assigned principal diagnosis of A41.9 (Sepsis, unspecified organism).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 22,2021, through July 29, 2022, and billed with diagnosis code 
A41.9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pre-fabricated knee orthosis with addition. 
 
You asked the Plan to pre-approve pre-fabricated knee orthosis with addition. You say that this is needed due 
to pain so the enrollee can do daily activities and tasks. The Plan denied your request. The Plan says the record 
does not show instability and joint laxity. 
 
The Plan follows Medicare rules. Medicare rules state that knee orthoses, and their additions, are only covered 
if certain 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 pre-fabricated knee orthosis with 
addition. Our reviewer says that the enrollee does not meet criteria for a knee orthosis with addition. Our 
physician reviewer found the records do not document any recent injury - or surgical procedure - to the knee or 
that the enrollee has knee instability documented by examination with objective description of joint laxity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pre-fabricated knee orthosis with addition have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a pre-fabricated knee orthosis with addition.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan and you can be treated within the Plan 
network. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits to be provided 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 ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
titration (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and 
a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to 
provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that after a lengthy critical hospital stay, the enrollee 
requires daily intensive therapy to regain maximum function. The Plan denied your request. The Plan says the 
requested IRF services are not medically necessary. 
 
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 do not 
require an IRF admission. The enrollees current medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including 
physical and occupational therapy, the documentation does not reveal that the enrollee requires this therapy on 
an intensive IRF level. 
 
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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service November 
16, 2022. 
 You asked the Plan to pay for procedure code 76700. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into 
payment for code 93976. 
 
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 code 76700 
is a column II code to column I code 93976. 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 procedure code 76700 billed for date of service November 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits and consultations (CPT code(s): 99449, 
99205, 99215, 88321, 88323, 88325) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is an in-network provider that can perform the services you need. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visits and consultations (CPT code(s): 99449, 99205, 99215, 88321, 88323, 88325) to be provided by 
an out-of-network provider.
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 you are appealing with records. The Plan 
denied your request. The Plan says the denial of LTACH service is correct. 
 
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 improving and more stable, so should only require short-
term additional acute care services that can safely be provided at the current facility until appropriate for 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 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 revascularization services (37221, 37225, 37227, 37229, 
37231). 
 
You asked the Plan to pre-approve revascularization services. You say that the enrollee's pain effects their 
activities of daily living. You say that the enrollee had an abnormal arterial ultrasound on June 8, 2022. You 
also say that the enrollee is unable to tolerate statin, has attempted anti-hypertensive therapy, and SET therapy. 
The Plan denied your request. The Plan says the requested services are 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 pre-approve revascularization services. Our 
reviewer says that the requested revascularization services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation includes evidence of lower 
extremity arterial disease, but the evidence does not confirm that treatment with maximal guideline-directed 
medical therapy, such as a program of structured exercise, medications such as a statin and cilostazol, and 
smoking cessation have been carried out. Therefore, the reviewer found that the requested revascularization 
services 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 revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services (37221, 37225, 37227, 37229, 37231).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight pharmacogenomics testing (81479) provided on 
August 10, 2022. 
 
You asked the Plan to pay for GeneSight pharmacogenomics testing. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the services at issue exceed the 
enrollee's medical need. 
 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 GeneSight pharmacogenomics testing. Our 
reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the available documentation indicates that the enrollee has no history of an 
adverse reaction to a psychiatric drug. There is no documentation of the enrollee's treatment history, including 
the duration of symptoms, duration of treatment, and medications used, or why genomics testing is believed to 
be 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 GeneSight pharmacogenomics testing have not been met. Therefore, we 
decided that the Plan does not have to pay for GeneSight pharmacogenomics testing (81479) provided on 
August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that given the enrollee's intolerance of the continuous positive airway pressure (CPAP) device mask interface, 
it seems unlikely the enrollee will be able to tolerate a home ventilator. Furthermore, BiPAP with average 
volume assured pressure support (AVAPS) has not been tried and shown to fail as an outpatient. Medicare does 
not cover a home ventilator when used as BiPAP or for the diagnosis of obesity hypoventilation syndrome.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the jAK2 (Janus kinase 2) variant (CPT code 81270). 
 
You asked the Plan to pre-approve the laboratory service. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the medical records show that the enrollee does not have indication 
that this test is medically necessary for 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 laboratory service. Our physician 
reviewer found there is no clinical rationale for the requested laboratory study. This enrollee has had symptoms 
since 2021. There are other non-genetic causes of the enrollee's symptoms that have not been ruled out. The 
review has determined that the medical records provided do not meet the requirements listed in the LCD for 
Medicare coverage. 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 laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the jAK2 (Janus kinase 2) variant (CPT code 
81270).
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 need this rehabilitation to regain full 
functionality and perform daily tasks after the back surgery. The Plan denied your request. The Plan says your 
records do not show that you have complex rehabilitation needs requiring frequent evaluation by a 
rehabilitation doctor, medically necessary care may be provided safely in a different 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. Our physician reviewer found clinical documentation shows you have complex functional impairments and active 
medical issues however evaluating physical therapist recommends intermittent therapy at home vs IRF in 
updated therapy notes thus intense therapy (15hrs of therapy per week) would not be required or medically 
necessary. 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.