Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health (HH) physical therapy (PT) visits 
(Current Procedural Terminology (CPT) code G0151 X 2). 
 You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident 
need for the services of a skilled physical therapist. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health physical therapy visits. 
Our reviewer says that [state physician reviewer's conclusion, e.g. "the service is not medically necessary." or 
"you need this medical item."] Our physician reviewer found the enrollee does not have documented, ongoing, 
home health (HH) physical therapy (PT) needs. The enrollee is functioning at a level commiserate with a lower 
level of care. As such, the requested, ongoing, HH PT is not medically necessary or reasonable. 
 
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 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health (HH) physical therapy (PT) visits (Current 
Procedural Terminology (CPT) code G0151 X 2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elective knee procedure and related inpatient hospital 
services provided from April 27, 2022, to May 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON surgery and inpatient care. You say that you feel that the Plan should 
pay for this surgery because you were not able to find a network surgeon that was able to provide the necessary 
care. You had been scheduled with a network surgeon who had some experience with the procedure, but due to 
scheduling issues, that surgeon became unavailable, and a less experienced surgeon was offered. You state that 
you were not comfortable with the new surgeon and sought care from the OON hospital as you were aware 
they had more experience in this treatment. You feel that the Plan should approve this retroactively because of 
the lack of experienced network providers. The Plan denied your request. The Plan says you cancelled a 
scheduled surgery with a network provider and opted to be seen OON. The Plan was not contacted to request 
authorization to be seen OON. This was an elective scheduled surgery, and there was time to request this 
authorization. As such, this was correctly denied as unauthorized non-emergent OON care. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. Though you had understandable 
concerns about the network surgeon at issue, there is no evidence that you requested authorization to have this 
surgery provided OON. It appears that there was more than one month between the cancelled in-network 
surgery and the OON surgery, but no authorization was requested during this period. 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 elective knee procedure and 
related inpatient hospital services provided from April 27, 2022, to May 4, 2022, by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing or therapy needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar transforaminal epidural injection. 
 
You asked the Plan to pre-approve a lumbar transforaminal epidural injection. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a lumbar transforaminal epidural 
injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
LCD criteria requires 3 months of greater than 50% pain relief. This was not achieved and so, the request is 
considered 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 a lumbar transforaminal epidural injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lumbar transforaminal epidural injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve poly casters (K0108), push handles (K0108) and side 
guards (K0108) for an approved wheelchair. 
 
You asked the Plan to pre-approve these features. You say that these items are medically necessary. The Plan 
denied your request. The Plan says these features are for use outside the home, and are non-covered. 
 
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.  
 
The items at issue in this appeal are for use outside of the home. Although these items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve poly casters (K0108), push handles (K0108) and side guards (K0108) for an approved 
wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided on October 01, 2021, to 
October 04, 2021. 
 
You asked the Plan to waive the copayment for SNF care. You say that you shouldnt have to pay for this. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $426 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $426 copayment for SNF care. This item/service falls within the Skilled nursing 
facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. You have been asked to pay $426 copayment for the SNF care which is less than the standard $184 
per day copayment because you met your out of pocket maximum during this stay. Therefore, we decided that 
the Plan does not have to waive the copayment for SNF care provided on October 01, 2021, to October 04, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a specialist visit. You say that your staff are struggling to keep up with the 
demand during this trying time. Many are ill and not available; therefore, preauthorization requests have been 
going out late. The Plan denied your request. The Plan says there was no preauthorization for an OON provider 
or facility, and this was not an emergency. Therefore, the payment is correct. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 a specialist visit provided on March 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient consultation provided on April 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient consultation. You say that the SNF should have obtained 
preauthorization before you arrived to treat the beneficiary. The Plan denied your request. The Plan says there 
was no preauthorization for an OON provider or facility, and this was not an emergency. Therefore, the 
payment is correct. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 an inpatient consultation provided on April 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for non radiological services provided on April 
08, 2022. 
 
You asked the Plan to waive the copayment for non radiological services. You say that you never had to pay 
this in the past so you shouldnt have too now. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for non-radiological diagnostic services. 
 
You have been asked to pay a $25 copayment for non radiological services. This item/service falls within the 
non-radiological diagnostic services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for 
non radiological services provided on April 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services (procedure codes 95911, 95885) provided 
to the enrollee on March 7, 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 these codes are not supported by the records. 
 
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: 
 
Current Procedural Terminology (CPT) 95885 - Needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited 
(List separately in addition to the primary procedure) 
 
Current Procedural Terminology (CPT) 95911 - Nerve conduction studies; 9 - 10 studies 
 
  
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 per CPT code description for CPT 
95885, "done with nerve conduction, amplitude and latency/velocity study." In this case, nerve conduction 
studies cannot be verified, therefore this procedure would not be covered. In terms of CPT 95911, the 
procedure report describes Pedical Testing ("Results Pedicle screw stimulation was performed with all 
stimulated repsonses above threshold values.  Surgion advised and acknowloged"). Per CPT Assistant May 
2013 "Use electromyography codes 95860-95864, 95869, 95870, 95885, or 95886 when performing 
monitoring during pedicle screw placement."  
 
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 neurology services (procedure codes 95911, 95885) provided to the enrollee on March 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 9 additional home health PT visits. You say that you are not able to leave 
home without help, so these visits are necessary. The Plan denied your request. The Plan says it has approved 6 
of the 15 requested home health PT visits, but the remaining 9 visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 9 additional home health PT visits. Our 
reviewer says that the requested 9 additional home health PT visits are not medically necessary. Our physician 
reviewer found the clinical documentation shows that you continue to have pain which is improving. All of 
your other listed mobility goals have been met, which is why 9 additional home health physical therapy visits 
are 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 9 additional home health PT visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 additional home health physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin, Pembrolizumab, Paclitaxel, Palonosetron, 
Dexamethaasone, Fosaprepitant IV, and Neulasta for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not support that this drug/regimen is reasonable and necessary. 
 
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 the services. Our reviewer says that the 
requested drugs are not medically reasonable and necessary. Our physician reviewer found that the 
combination of Carboplatin, Pembrolizumab, Paclitaxel is not FDA approved for progression of non-small cell 
lung cancer while on prior immunotherapy. This patient progressed while on adjuvant atezolizumab. Use is not 
supported by the medical literature or major drug compendia. The service is not reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Carboplatin, Pembrolizumab, Paclitaxel, Palonosetron, Dexamethaasone, Fosaprepitant 
IV, and Neulasta for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx prostate cancer testing provided on August 25, 2021. 
 
You asked the Plan to pay for the SelectMDx test. You say that this test was medically necessary and 
reasonable. The Plan denied your request. The Plan says that this test was not medically necessary for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the SelectMDx test. Our reviewer says that 
the SelectMDx test is considered medically reasonable and necessary in this case. Our physician reviewer 
found National Comprehensive Cancer Network (NCCN) Guideline Version 2022 Prostate Early Detection, 
includes the following statement regarding this test: Overall, the panel believes that SelectMDx score is 
potentially informative in patients who have never undergone biopsy, and it can therefore be considered in such 
individuals. 
 
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 SelectMDx test have been met. Therefore, we decided that the Plan has to 
pay for the SelectMDx prostate cancer testing provided on August 25, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) test provided on 
May 3, 2022. 
 
You asked the Plan to pay for the urine PCR test. You say that this testing was medically necessary and should 
be paid. The Plan denied your request. The Plan says the enrollee does not meet criteria for necessity for this 
test. 
 
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 the urine PCR test. Our reviewer says that 
the urine PCR test is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical notes would need to show the member had evidence of a urinary tract infection (UTI), such 
as a urinalysis or urine culture consistent with an infection. The medical records submitted contained a copy of 
the PCR results only. No other clinical records were submitted that detailed the presence of a UTI, the 
completion of a standard culture and sensitivity, evidence of an immunocompromised state, a history of 
antibiotic resistance in treating the urinary tract infection in the member's clinical notes. The PCR testing 
without evidence of a UTI in the clinical notes does not meet the standard of medical necessity. 
 
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 urine PCR test have not been met. Therefore, we decided that the Plan does 
not have to pay for the urine polymerase chain reaction (PCR) test provided on May 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you have nowhere to live and are not capable of 
caring for yourself. You can only live safely in the SNF setting. The Plan denied your request. The Plan says 
you do not need daily skilled care. Your needs are mostly custodial at this time. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is a female with trouble walking and dementia, which has caused falls. 
From a nursing perspective, the enrollee requires oral medications and has stable vital signs. Regarding 
rehabilitation services, the enrollee has had physical and speech therapy. She requires minimal assistance with 
functional mobility and tolerates a mechanical soft diet and thin liquids.  
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, these do not require daily skilled therapy services. This enrollee does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.