Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 24 outpatient physical therapy sessions. 
 
You asked the Plan to pre-approve an additional 24 outpatient physical therapy sessions. You say that you feel 
the therapy services should be covered because you are showing signs of better control of higher resistance 
during most exercises. You say it is critical to your health and mobility that you continue physical therapy 
treatment in order to use the specialized equipment. The Plan denied your request. The Plan says the clinical 
notes indicate you are stable to rehabilitate with an at home exercise program.  
 
 
 You were previously approved for 341 visits which should meet the clinical expectations for treatment. 
Furthermore, the Plan says the documentation does not support a need for services to be performed by a 
qualified therapist. You can safely and effectively continue treatment at home.  
 
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 outpatient physical therapy. 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 been receiving physical therapy to treat 
a chronic knee pain condition. Our reviewer found that you have demonstrated improvement in both strength 
and movement during your previous 341 therapy visits. Moreover, the medical documentation reveals you are 
able to walk over 300 feet with a walker.  
 
Our physician reviewer says an at home exercise program should be sufficient. There is no documentation 
supporting a decline in function or development of a recent injury that would otherwise justify further skilled 
therapy treatments. The additional therapy services are neither an appropriate duration nor frequency for 
treatment of your medical condition. Therefore, our reviewer says these additional therapy sessions 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 outpatient physical therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 24 outpatient physical therapy sessions.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says the enrollee has not 
tried one of the preferred drugs. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Monovisc. Our physician reviewer 
found that the enrollee has bilateral primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc, 
Synvisc, or Synvisc-One before they will approve the requested drug. The case file does not contain 
documentation of trial and failure of one of the preferred drugs. The documentation does not support that the 
Plans preferred drugs would likely be less effective or would 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided to the enrollee on 
September 24, 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, the CPT Code Manual definition of code 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter." 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the enrollee was seen by this 
same provider less than three years ago. The enrollee would not be considered a new patient. 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 a new patient office visit provided to the enrollee on September 
24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (heel lift). 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (heel lift).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing (83789) provided on April 13, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing.  
 
We looked at the file and Medicare rules. The service in question is specimen validity testing. This type of 
testing is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the specimen validity 
testing (83789) provided on April 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional home health physical therapy (PT) visits, 
17 additional home health occupational therapy (OT) visits, and 6 additional home health skilled nursing (SN) 
visits. 
 
You asked the Plan to pre-approve additional PT, OT, or SN visits. 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 enrollee has already been educated on a home exercise program. The Plan also says that there is 
no documentation of an active or acute on chronic condition that would necessitate a new program. 
 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 additional PT, OT, or SN visits. Our 
reviewer says that the health plans denial should be upheld. Our physician reviewer found you are functioning 
at a level that does not support the quantity of services requested. The health plan has partially approved care, 
after which additional documentation is warranted to determine if additional services are necessary. Our 
reviewer also found that the services initially requested are not shown to be 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 additional PT, OT, or SN visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 12 additional home health physical therapy (PT) visits, 17 additional 
home health occupational therapy (OT) visits, and 6 additional home health skilled nursing (SN) visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion/specialty drug administration (99601) 
provided on July 13, 2020. 
 
You asked the Plan to pay for the home infusion/specialty drug administration. You say that this claim has not 
been paid in full or under the terms of the contract for the services provided. The Plan denied your request. The 
Plan says this service is excluded from coverage. 
 
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 CPT code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the home infusion/specialty drug administration have not been met. Therefore, we decided that the 
Plan does not have to pay for the home infusion/specialty drug administration (99601) provided on July 13, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab test on June 16, 2021. 
 
You asked the Plan to waive the copayment for lab test. You say that you want a refund of all your copays you 
paid in 2021. The Plan denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
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 $10 
copayment for each covered lab service. Covered services include but are not limited to: Laboratory tests. 
 
You have been asked to pay a $10 copayment for lab test. Lab tests fall within the Outpatient diagnostic tests 
and therapeutic services and supplies 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 
lab test on June 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. The Plan denied your request. The Plan says this request is not 
medically necessary because there are multiple injuries within the knee that are likely contributing to the pain, 
including a stress fracture, and there is no sign of osteoarthritis on the magnetic resonance imaging (MRI), as 
the cartilage is reported as normal.  
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all 
of the conditions listed in the Medicare rules section above 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 Orthovisc. Our reviewer says that the 
enrollee does not meet the criteria for coverage. Our physician reviewer found the records show the enrollee 
has derangement of the left knee with meniscal tears, muscle strains and a stress fracture. The magnetic 
resonance imaging reveals normal cartilage within the knee joint space. Our reviewer found that there is no 
documentation of osteoarthritis. Our physician reviewer also found that the review has determined that the 
enrollee does not meet all of the conditions which are indicated for 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc (J7324).
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 the full criteria for an IRF stay. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 improving but still requires acute care services before transitioning to 
a lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that she is not currently receiving but that 
would be available at the LTACH 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided January 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says the records do not support that the service is 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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found high grade neuroendocrine cancer is treated as small cell carcinoma. Tecentriq with 
chemotherapy is approved for metastatic disease as immunotherapy to be used, and there are no other 
actionable mutations. 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus Gene Panel provided January 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of thorax (71250) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve CT scan. You say that the service is medically necessary. The Plan denied 
your request. The Plan says there are in network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
You are not a network provider with the Plan. The Plan has network providers available who can provide the 
CT 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 computed tomography (CT) of thorax 
(71250) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve out-of-network care. You say that you were unhappy with the care and 
information provided by one of the Plan providers, which conflicts with information you were given by another 
Plan provider. You want another opinion from someone out-of-network. The Plan denied your request. The 
Plan says there are specialists in-network who can provide the necessary care. You have had second opinions 
and are scheduled for surgery with a Plan provider. 
 
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 
a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic angiography 
(CTA) provided on February 21, 2022. 
 
You asked the Plan to waive the copayment for the CTA. You say that you were told two different amounts 
when you asked about the cost. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $225 
copayment for each advanced imaging service, including CT scans.  
 
You have been asked to pay $164.21, which is less than the $225 copayment for the CTA. The CTA falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a computed tomographic angiography (CTA) provided on February 
21, 2022.