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

 
We decided that the Plan does not have to pre-approve an out-of-network referral for magnetic resonance 
imaging (MRI) of the cervical spine. 
 
You asked the Plan to pre-approve the referral. You say that this is needed to get your life back to a sense of 
normalcy. The Plan denied your request. The Plan says there is an in-network provider readily available. 
 
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 
an out-of-network referral for magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio for the enrollee. 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the member has not tried and failed the preferred step therapy drug, Stelara. 
 
 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 Entyvio. Our reviewer says that 
Entyvio is not medically reasonable and necessary. The Plan requires a trial of Remicade, Inflectra, or 
Infliximab; AND a trial of Stelara before they will approve the requested drug. In this case, the patient has not 
tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found 
that the enrollee's condition does not meet step therapy criteria for Entyvio. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio for the enrollee.
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 LTACH services. You say that LTACH care is a medical necessity for you. 
The Plan denied your request. The Plan says medical necessity rules for LTACH care have not been met. 
 
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 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 you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving 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 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 level 5 molecular pathology procedure (81404) provided 
on July 31, 2021. 
 
You asked the Plan to pay for the level 5 molecular pathology procedure. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the ordering 
physician on the claim did not order this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the level 5 molecular pathology procedure have not been met. Specifically, the records submitted 
indicate that this testing was not ordered by the enrollee's treating physician. Therefore, we decided that the 
Plan does not have to pay for the level 5 molecular pathology procedure (81404) provided on July 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services provided to the enrollee on April 16, 
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 service codes cannot be substantiated. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
 
 CPT 75716: 
 
Angiography, extremity, bilateral, radiological supervision and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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 the procedures were billed with 
modifier -59; however, there is no documentation that supports them as distinct procedural services. Therefore, 
they should not be reported with CPT 37225. 
 
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 angiography services provided to the enrollee on April 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says according to the 
available records, you do not meet all the required Medicare criteria for admission to an IRF. The Plan also 
says that you are at or near baseline function and do not require physician supervision by a rehabilitation 
physician. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have 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 you 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 occupational therapy visits for the enrollee. 
 
You asked the Plan to pre-approve 12 occupational therapy visits. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the clinical documentation does not show that the 
unique skills of an occupational therapist are required to provide treatment safely and effectively. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 12 occupational therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of 12 occupational therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 occupational therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 12 occupational therapy visits for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 2, 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 they should have billed with no modifier if billing for both components. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
CPT 73110: 
 
Radiologic examination, wrist; complete, minimum of 3 views 
 
CPT 73130: 
 
Radiologic examination, hand; minimum of 3 views 
 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 the services were incorrectly billed 
with a modifier. A mobile x-ray company performed the x-ray, and was read by the radiology; therefore, this 
procedure would not have a modifier appended. When determining if the technical and professional 
components were performed by the "same provider" or by different providers, if both components will be billed 
under the same tax ID number (TIN) then both components were performed by the same provider and are not 
eligible to be reported as separate components. Instead, the global service should be billed without modifier 
technical component (TC) or 26. 
 
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 imaging services provided to the enrollee on July 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Paclitaxel (CPT code J9267). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee was recommended single agent 
paclitaxel for recurrent and progressive squamous carcinoma of the skin progressing after the use of 
cemiplimab. You state paclitaxel is recommended as single agent to reduce toxicity and maintain quality of life 
as palliative treatment. The Plan denied your request. The Plan says the use of paclitaxel as single agent 
therapy is not The Food and Drug Administration (FDA) approved for this type of cancer and there is lack of 
support for its use in the Medicare references. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the requested use of Paclitaxel (CPT code J9267), is not The Food and Drug Administration (FDA)-approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal as a single agent. 
 
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 Paclitaxel (CPT code J9267).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Stretta procedure (CPT code 43257). 
 
You asked the Plan to pre-approve the Stretta procedure. You say that you have a pacemaker, and do not want 
to have an invasive procedure that requires a hospital stay and is associated with known complications of 
dysphagia and the gas-bloat syndrome. You state the Stretta procedure is not associated with any significant 
morbidity or safety issues. The Plan denied your request. The Plan says the Medicare guidelines say that this 
item or service is not covered, as it is not considered reasonable and necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the Stretta procedure have not been met. Currently, these 
procedures other than TIF are considered non-covered due to the fact that current peer- reviewed literature does 
not support the long-term efficacy and long-term safety of the services. Claims will be denied as "not proven 
effective." Therefore, we decided that the Plan does not have to pre-approve the Stretta procedure (CPT code 
43257).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with an out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network office visits. The Plan denied your request. The Plan says in-
network providers are available. 
 
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 with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that you would like reconsideration because the 
Monovisc is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet step-
therapy exception criteria. 
 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 Monovisc. Our reviewer says that the 
Plan requires a trial of Gel-One and Syncisv-One before they will approve the requested drug. The case file 
does not contain documentation of trial and failure of Gel-One and Syncisv-One. 
 Our physician reviewer found the documentation does not support that Gel-One and Syncisv-One would likely 
be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayments for the medical services provided from August 6, 2021, 
through September 3, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 Plan has not provided adequate information to evaluate the cost 
sharing liability in this case. Therefore, we decided that the Plan has to waive the copayments for the medical 
services provided from August 6, 2021, through September 3, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete series of radiographic images (D0210) 
provided on January 6, 2022. 
 
You asked the Plan to pre-approve the complete series of radiographic images. You say that you would like 
reconsideration because this service was necessary to fix a poorly fitting crown. The Plan denied your request. 
The Plan says this service exceeds the frequency limitation. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested complete series of x-rays 
is only covered once every three plan years. The records show that you received a complete series of 
radiographic images on February 18, 2020. This service exceeds the frequency limitation as shown in your contract with the Plan. Therefore, we decided that the Plan does not have to pre-approve the complete series of 
radiographic images (D0210) provided on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (11043) provided on October 27, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 11043 is a column II code to column I code 11044. 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 (11043) 
provided on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 15, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
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 lab 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 lab services provided on September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee would 
not be expected to benefit significantly from the intensive therapy program. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee has a past medical history of hypertension, anxiety, and insomnia. He is being treated as an 
outpatient for infected wounds of the lower extremity with oral antibiotics and wound care. There is weakness 
and trouble ambulating. Other medical problems are stable. While he has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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.