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

 
We decided that the Plan does not have to pre-approve treatment with Trelstar. 
 
You asked the Plan to pre-approve Trelstar. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 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 Trelstar. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Lupron before they will approve the requested drug, Trelstar. There is no indication in 
the case record that the enrollee has tried and failed the required drug. Based on the medical records provided 
and the Medicare-approved major drug compendia, there is no indication that the Plan's required drug would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trelstar have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Trelstar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says a BiPAP 
will meet the enrollee's needs. 
 
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 physician 
reviewer found that the enrollee has a history of COPD and was recently hospitalized with acute respiratory 
failure. The arterial blood gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure. The 
enrollee improved with BiPAP. There is no pulmonary function test to confirm the severity of the COPD, and 
no ABG done while stable to confirm chronic carbon dioxide (CO2) retention. If this enrollee does have 
chronic CO2 retention, BiPAP with advanced volume-assured pressure support (AVAPS) during sleep may be 
of benefit. However, Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. Therefore, the request 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit option (K0108), push handles (K0108) and a 
seat belt mounting kit (E0978) for an approved wheelchair. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these features are medically 
necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare rules also say that if an option or accessory that is included in 
another code is billed separately, the claim line will be denied as not separately payable. 
 
The transit accessory at issue in this appeal is for use outside of the home. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. The push handles and seat belt 
mounting kit are included in the base wheelchair code and are not separately billable. Therefore, we decided 
that the Plan does not have to pre-approve a transit option (K0108), push handles (K0108) and a seat belt 
mounting kit (E0978) for an approved wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
presented with right sciatica and positive straight leg rise. The neuro exam from 3/13/23 was normal. There is 
no localized tenderness in the thoracic spine. There are no plain films of the thoracic spine done. There are no 
thoracic dermatome symptoms. Absent any clinical history or other physical/imaging findings suggesting 
thoracic spine pathology, the medical necessity of the thoracic spine MRI has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the thoracic spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 2, 2022, to 
May 6, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation audit was performed to help ensure that the diagnosis codes on the claim supported clinically, and the DRG 
was updated. 
 
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 DRG 193. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented to the emergency department (ED) with shortness of breath, cough, and hypoxia, 
requiring 3L/m oxygen support via nasal cannula. A chest x-ray revealed pneumonia. The enrollee was treated 
with IV fluids, antibiotics, bronchodilators, and continued low dose oxygen (2-3L/m) throughout workup and 
treatment. The patient does not meet definition of acute respiratory failure as she was not in acute respiratory 
distress and did not require high flow oxygen support, bilevel positive airway pressure (BiPAP), or vent 
support. Therefore, DRG 194 would be more appropriate for this admission.  
 
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 rendered from May 2, 2022, to May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit (90834) provided on August 3, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy service. You say that claims for this enrollee from other dates 
of service have been paid. You say that this should be paid too. The Plan denied your request. The Plan says 
services received out-of-network are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the psychotherapy visit (90834) provided on August 3, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx testing (0315U) provided on August 10, 2022. 
 
You asked the Plan to pay for DecisionDx testing. You say that this is an approved test which was performed 
by a certified laboratory with a referral from the enrollee's treating physician. The Plan denied your request. 
The Plan says the claim for this molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of DecisionDx testing 
have not been met. Therefore, we decided that the Plan does not have to pay for DecisionDx testing (0315U) 
provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual wheelchair including tilt in space and 
accessories 
 
You asked the Plan to pre-approve the wheelchair. You say that the custom wheelchair is needed due to the 
current facility wheelchair not meeting the enrollee's needs. The Plan denied your request. The Plan says the 
enrollee resides in a long-term care facility. The Medicare DME benefit does not cover DME in a SNF or 
hospital. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve the manual wheelchair including tilt in space and accessories
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that Zilretta 
is medically necessary. Our physician reviewer found the requested drug is being used for its current Food and 
Drug labelled indication. The record indicates that the enrollee has had benefit from the requested drug 
previously. The Food and Drug Administration has not restricted its use to a single time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L5-S1 anterior lumbar interbody fusion with 
posterior percutaneous instrumentation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
not a plan to take pressure off the pinched nerve. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spondylolisthesis of the lumbar region. She has weakness 
on her right foot. She had a bone density scan and notes she has osteopenia. The exam reveals 4/5 in the 
bilateral hip flexion and 4-4-/5 in left dorsiflexion. Detailed documentation is not evident regarding a trial and 
failure of recent, reasonable, comprehensive less invasive conservative care measures. Additionally, dynamic 
flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at 
the requested surgical level. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested an L5-S1 
anterior lumbar interbody fusion with posterior percutaneous instrumentation, in this case, is not medically 
reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an L5-S1 anterior lumbar interbody fusion with posterior percutaneous 
instrumentation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service August3, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the denial. The Plan 
denied your request. The Plan says the documentation did not support the billed code. 
 
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 definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the lab results provided do 
not show that 15-21 drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0482 billed for date of service August3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say the enrollee requires LTACH services for the 
ongoing management of acute care needs. The Plan denied your request. The Plan says admission to the 
LTACH is not medically necessary. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility, and transfer to the LTACH is not medically necessary as the 
enrollee is not yet stable it would not be clinically advantageous at this time. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are 
necessary due to the complex nature of the enrollee's illness. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare guidelines for care in 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 enrollee appears to be improving on current treatment and should only 
require short-term additional acute care hospital services that can safely be provided at the current facility until 
more stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous at this time.  
 
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 LTACH 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 enrollee's current medical condition requires 
rehabilitation. The Plan denied your request. The Plan says the enrollee's care needs can be met in 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 the complexity of the enrollees nursing medical and rehabilitation needs may benefit 
from an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  However, the 
enrollee is noted to have difficulty tolerating therapy and it is not clear that the intensity of therapy services 
provided in acute inpatient rehabilitation can be tolerated. The enrollee must be able to participate in multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program at least three hours a day and five days a week, or 15 hours over seven consecutive days. Therefore, 
the acute inpatient rehabilitation admission is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92941, 93458, 99152 rendered on July 8, 
2022. 
 
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 records do not support the services billed. 
 
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 92941: Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute 
myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, 
atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel 
 
CPT 93458: Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural 
injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization 
including intraprocedural injection(s) for left ventriculography, when performed 
 
CPT 99152: Moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
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 the medical records provided do 
not include sufficient documentation to validate that these procedures were rendered in this case. These 
services cannot be verified. 
 
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 procedure codes 92941, 93458, 99152 rendered on July 8, 2022.