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

 
We decided that the Plan does not have to pay for molecular pharmacogenetic testing provided to the enrollee 
on April 19, 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 a panel constitutes a single procedural service, so one CPT code must be submitted for the panel. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Therefore, we decided that the Plan does not have to pay 
for molecular pharmacogenetic testing provided to the enrollee on April 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6mg/kg dosage of Inflectra. 
 
You asked the Plan to pre-approve 6mg/kg dosage of Inflectra. The Plan denied your request. The Plan says the 
requested dosage exceeds what is indicated by accepted standards of medical practice for your condition. 
 
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 6mg/kg dosage of Inflectra. Our 
reviewer says that the requested dosage is not medically reasonable and necessary. Our physician reviewer 
found that the Medicare-approved major drug compendia do not support the requested Inflectra dose for the 
diagnosis documented in the provided medical records. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6mg/kg dosage of Inflectra have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 6mg/kg dosage of Inflectra.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre sensor kit (K0553) provided on August 28, 
2021. 
 
You asked the Plan to pay for a Freestyle Libre sensor kit. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the provided records do not discuss a continuous glucose monitor and related 
supplies. Therefore, we decided that the Plan does not have to pay for a Freestyle Libre sensor kit (K0553) provided on 
August 28, 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. You say that the enrollee requires 3 hours of therapy a day in the 
hospital setting. You also say that the enrollee's medical needs need to be monitored at all times. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in an IRF. 
 
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 IRF admission is not medically necessary based on lack of medical complexity, and 
lack of acute rehabilitation nursing needs and high functional mobility. Our reviewer also found that while the 
enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be 
safely met in an alternate and lower intensity 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided the Plan does not have to pay for a portable oxygen concentrator purchased on February 24, 2021. 
 
You asked the Plan to pay for this equipment. You say that you purchased this type of equipment in 2016 and 
the Plan covered it. The Plan denied your request. The Plan says the equipment purchased in 2016 was covered 
as a courtesy because the customer service person did not fully explain your benefits. However, you were fully 
aware of your Plan rules for durable medical equipment after that event and did not have prior authorization to 
purchase new equipment. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The Plan contract states that 
durable medical equipment requires prior authorization. As of the appeal in 2016, you were fully aware of your 
Plans rules regarding this type of equipment. You did not have prior authorization. The equipment was 
purchased out of network; therefore, the Plan is not required to hold the provider responsible for getting prior 
authorization. We found no exception that would require the Plan to pay for this equipment. Therefore, we 
decided that the Plan does not have to pay for a portable oxygen concentrator purchased out of network on 
February 24, 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. You say that the enrollee meets criteria for IRF care. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found that on review of the available records, the enrollee is medically stable. She does 
not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. At the current 
functional level, she does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 
5 days per week with multidisciplinary approach to daily therapy. She needs speech, physical and occupational 
therapy in a lower intensity level. IRF admission is not medically necessary based on lack of medical 
complexity, and lack of acute rehabilitation nursing needs. The documentation does not support the necessity 
for admission to an IRF. While the enrollee may benefit from speech, physical and occupational therapy, the 
enrollee's rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on June 27, 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 an edit exists between CPT 70450 and 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Modifier -26 is not supported for this case. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services 
provided to the enrollee on June 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous process spacer device (22867). 
 
You asked the Plan to pre-approve the Coflex procedure. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says insertion of interspinous/interlaminar 
process spacer devices including Coflex is considered experimental and/or unproven as there is not enough 
medical proof that shows the safety and/or success of this treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Coflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve interspinous process spacer device (22867).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on September 13, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 radiology services provided to the enrollee on September 13, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 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 provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70480 
is a column II code to column I code 70450. 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 imaging services provided to the enrollee on October 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve CPAP device. You say that the enrollee is in need of CPAP therapy. The 
Plan denied your request. The Plan says the denial of authorization for this device is correct, because the 
enrollee was only 18% compliant during the trial period. 
 
The Plan follows Medicare rules. Medicare rules state that continued use of a positive airway pressure (PAP) 
therapy beyond the first three months requires documentation of benefit including use of the PAP 4 or more 
hours per night on 70% of the nights during the first 3 months. 
 
 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 CPAP device. Our reviewer says that 
the enrollee does not meet the Medicare criteria for continued use of a CPAP device. Our physician reviewer 
found the record indicates that the enrollee has sleep apnea due to traumatic brain injury. The record indicates 
that the enrollee is compliant with treatment 18% of the time. Therefore, the records do not show that the 
enrollee has qualified for continued CPAP use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a continuous positive airway pressure (CPAP) device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 an epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found according to Medicare rules in the LCD, "repeat epidural steroid injections (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using SAME scale for at 
least three (3) months."   In this case, the two prior lumbar Transforaminal ESIs did not yield 3 months of pain 
relief.  The review has determined that the enrollee does not meet the above LCD criteria for the requested 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) chest (71250). 
 
You asked the Plan to pre-approve a CT scan. You say that the CT was ordered because previous CT 
angiogram showed abnormalities. The Plan denied your request. The Plan says the clinical documentation 
submitted does not demonstrate medical necessity and the requested study does not meet Medicare criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case Our physician 
reviewer found the record indicates that the enrollee had COVID-19 infection in August 2021 ad had 
undergone a CT angiogram at the time demonstrating characteristic lung findings. Short term follow up was 
recommended. The provided records do not indicate the medical necessity or reasonableness, as defined by 
Medicare rules, of the requested service at this time. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) chest (71250).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be rendered by the out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy sessions to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy sessions. You say that you have seen this provider 
before and would like to continue to see this provider. The Plan denied your request. The Plan says a list of in-
network providers was given to the enrollee that provide the same service. 
 
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 
physical therapy sessions to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81240, 81241). 
 
You asked the Plan to pre-approve the genetic testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the requested test is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the F2 and F5 genetic tests are not considered to 
be clinically efficacious; therefore testing is not medically necessary and non-covered. 
 
We looked at the file and Medicare rules. This genetic test is non-covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve genetic testing (81240, 81241).