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

 
We decided that the Plan does not have to pre-approve Euflexxa knee injection services. 
 
You asked the Plan to pre-approve Euflexxa knee injection services. You say that previous injections are not 
working, and you need the requested injections to help with your pain. You say that without the requested 
injection services you cannot walk. The Plan denied your request. The Plan says the requested injections are 
not covered because it has not been 6-months since your prior injections. 
 
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 Euflexxa knee injection services. Our 
reviewer says that Euflexxa knee injection services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a history of bilateral knee pain due to osteoarthritis. 
She has been treated with medical therapy and viscosupplementation with Euflexxa. She had her last Euflexxa injections in November 2022. A repeat series of injections may be allowed when the indications continue to be 
met; and significant improvement in pain and functional capacity from the prior series of injections is 
documented in the medical record; and the last injection (in a prior course) was given at least six (6) months 
ago. It has not been at least 6 months since the previous injections to warrant repeat injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa knee injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Euflexxa knee injection services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary as the enrollee requires 
daily medical over site and therapy services. The Plan denied your request. The Plan says the enrollee's needs 
can be met at lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found documents do not support necessity for admission to an IRF.  The complexity of the 
enrollee's nursing, rehab, and medical needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. While the enrollee may benefit from physical and occupational 
therapy, their rehab needs can be provided in a lower intensity and alternate setting such as in a skilled nursing 
facility. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot afford this service, you are in 
pain, and it is imperative it is approved. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on authorization number 0042790531 when 
the Plan approved this procedure in a different quadrant. Therefore, we decided that the Plan does not have to 
pre-approve removal of torus mandibularis (D7473).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Percutaneous implantation of neurostimulator 
electrode array (63650) and Implantable neurostimulator electrode (L8680). 
 
You asked the Plan to pre-approve the Percutaneous implantation of neurostimulator electrode array and 
Implantable neurostimulator electrode. You say that the service is medically necessary. The Plan denied your 
request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the implantation of the stimulator is used only as a 
late resort (if not a last resort) for patients with chronic intractable pain. 
 
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 Percutaneous implantation of 
neurostimulator electrode array and Implantable neurostimulator electrode. Our reviewer says that the service 
is not medically necessary. Our physician reviewer found the patient has several evidence-based interventions 
available to him and this is not a late or last resort. 
 
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 Percutaneous implantation of neurostimulator electrode array and 
Implantable neurostimulator electrode have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Percutaneous implantation of neurostimulator electrode array (63650) and Implantable 
neurostimulator electrode (L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (17110) provided on October 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors shall automatically deny claim line(s) 
items submitted with a GZ modifier. Contractors shall not perform complex medical review on claim line(s) 
items submitted with a GZ modifier.  
 
We looked at the file and Medicare rules. In this case, code 17110 was billed with a GZ modifier. As such, 
code 17110 is not payable. 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 services (17110) 
provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective restoration service (D2940). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a protective 
restoration service (D2940).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for surgical management of left temporal brain lesion. Your medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with advanced K3 level components 
(L5668, L5981, L5984). 
 
You asked the Plan to pre-approve a prosthetic leg with advanced K3 level components. You say that the 
enrollee needs a K3 prosthesis. The Plan denied your request. The Plan says the records do not support that the 
enrollee is a K3 ambulator. The K3 foot exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria list in the rules section for a prosthetic leg 
with advanced K3 level components must be met for the prosthesis to be 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 prosthetic leg with advanced K3 level 
components. Our reviewer says that the service is not medically necessary. Our physician reviewer found that a 
level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of the community 
ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic or 
exercise activity that demands prosthetic utilization beyond simple locomotion. In this case, the documentation 
doesn't indicate that the enrollee is able to ambulate at a K3 level.  The requested K3 level prosthesis with 
upgraded components 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 a prosthetic leg with advanced K3 level components have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with advanced K3 level 
components (L5668, L5981, L5984).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that do not have money to pay your utility 
bills. The Plan denied your request. The Plan says there is no documentation that all the criteria has been met. 
 
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 SSBCI benefits. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have heart failure (grade III diastolic dysfunction), obesity, low back pain, 
peripheral edema, hypertension, and constipation. The provided documentation described you as stable on 
current treatment by your physician and without documentation of requiring intensive care or life-threatening 
status of your conditions or at risk for hospitalization to meet criteria for SSBCI 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 SSBCI benefits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Janus kinase 2 (JAK2) targeted sequence gene analysis 
(81279), F2 gene analysis (81240) and F5 gene analysis (81241). 
 
You asked the Plan to pre-approve JAK2, F2 and F5 gene analysis. You say that the enrollee needs these 
procedures. The Plan denied your request. The Plan says this equest is not medically necessary because the 
enrollee's records do not show that diagnostic criteria for polycythemia vera are met, and the enrollee has not 
had prior JAK2 V617F testing. 
 
The Plan follows Medicare rules. Medicare rules say that JAK2 gene analysis may be covered when the criteria 
in the rules section are met. F2 and F5 gene analysis is non-covered except for pregnant enrollees. 
 
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 JAK2, F2 and F5 gene analysis. Our 
reviewer says that JAK2 gene analysis is not medically necessary. Our physician reviewer found that enrollees 
suspected of having polycythemia vera or other myeloproliferative disorders are evaluated with a JAK2 
mutation. However, this enrollee has normal blood counts.  Enrollees with hepatic and portal vein thromboses 
should also be evaluated for JAK2 mutations. However, this enrollee had pulmonary emboli that were 
provoked. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Our physician reviewer found that the JAK2 
gene analysis is not medically necessary. The F2 and F5 gene analysis are not covered except for pregnant 
enrollees. Based on this information, we decided that Medicare rules for coverage of JAK2, F2 and F5 gene 
analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve Janus kinase 2 
(JAK2) targeted sequence gene analysis (81279), F2 gene analysis (81240) and F5 gene analysis (81241).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electroencephalogram (EEG) testing (code 95955) 
provided on May 20, 2022. 
 
You asked the Plan to pre-approve EEG testing. You say that the EEG testing was medically necessary. The 
Plan denied your request. The Plan says the EEG testing was 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 EEG testing. Our reviewer says that the 
requested EEG testing is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that intraoperative EEG monitoring is not indicated during lumbar spine surgery. The value of 
EEG monitoring in this setting has not been sufficiently demonstrated in the medical literature. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EEG testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve EEG testing (code 95955) provided on May 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not aware that non-transport services arent covered. You also say that you weren't the one who called the 
ambulance. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures. 
 
You asked the Plan to pre-approve the dental services. You say that you had a root canal and now your 
dentures do not fit. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 20, 2021. This 
benefit will not available again until September 20, 2026. Therefore, we decided that the Plan does not have to 
pre-approve dentures.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on October 25, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services are supported in the medical record and 
were reported correctly. The Plan denied your request. The Plan says that the code used to report the services 
provided is not supported in the medical record. 
 
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 
code G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records support that 15 drug 
classes were tested on the date in question. Based on this information, we decided that Medicare rules for 
coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on October 25, 2022.  
 
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: 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 the LTACH level of care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
admission to an LTACH. 
 
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 documentation does not support that the enrollee has a need for complex 
medical treatment in a LTACH. The enrollee does not require services at the LTACH that are not available at 
an acute care hospital or a skilled nursing facility.  The requested treatments are not medically necessary at the 
LTACH level of care.  The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate.   
 
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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional PT visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the additional PT visits are medically 
necessary due to your current medical condition. The Plan denied your request. The Plan says the member is 
stable to continue rehabilitation with the home exercise program and follow-up with their physician. 
 
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 additional PT 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 you have an effective treatment plan and may continue with a 
home exercise plan. You have achieved satisfactory recovery and unique input from a skilled therapist is no 
longer 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional PT visits.