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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care. You are walking 
household distances with a wheeled walker with stand-by assistance/supervision and is stand-by 
assistance/supervision for transfers. You do not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Services in the home or an assisted living facility with home health care or in a long-
term care facility on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing billed for services on April 14, 
2021. 
 
You asked the Plan to pay for the testing services. You say that there has been a misinterpretation of guidelines. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim lists a place of service as an independent laboratory. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not indicate that the specimen was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 testing billed for services on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic (CT) colonography, screening, 
including image post-processing for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is not medically necessary. The Plan denied 
your request. The Plan says Medicare does not cover this test. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary. Medicare does not consider CT colonography to be medically necessary. 
 
 
 
 
 The requested CT scan is not considered medically reasonable or necessary by Medicare at this time. 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 computed tomographic (CT) colonography, screening, 
including image post-processing for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (procedure code 99291) provided to the 
enrollee on May 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 Current Procedural Terminology (CPT) code 99291 remains not supported. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there was no documentation 
showing the time spent providing the critical care services. This documentation is necessary as CPT 99291 is a 
time-based code. 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 critical care services (procedure 
code 99291) provided to the enrollee on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that there has been a misinterpretation of guidelines. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim lists a place of service as an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on July 26, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine and upper 
extremity for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that no additional imaging is necessary at this time. 
 
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 imaging is medically reasonable and necessary. Our physician reviewer found in terms of the right 
shoulder MRI, the enrollee has pain, weakness, positive Hawkin's, Neer's and empty can signs, which are 
highly suspicious for rotator cuff tear. This would be a valid indication for an MRI. In terms of the cervical 
spine MRI, there is a history of prior fusion in 2020. The enrollee had had physical therapy in the past, and 
most recently, an epidural steroid injection. The right upper extremity symptoms also could be related to 
cervical radiculopathy or a combination.  MRI of the cervical spine is also indicated. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the cervical spine and upper extremity for the enrollee.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic-coated hand rims. 
 
You asked the Plan to pre-approve plastic-coated hand rims. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this is a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve plastic-coated hand rims.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97139) provided on August 6, 2020, 
through December 14, 2020. 
 
You asked the Plan to pay for the manual therapy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the unlisted procedure does not specifically 
identify manual manipulation of the spine. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the manual therapy (97139) provided 
on August 6, 2020, through December 14, 2020. have been met. Specifically, the documentation submitted 
does not include any medical records. Without this information we are unable to determine what services were 
rendered. Additionally, the billed unlisted therapeutic procedure code does not accurately indicate what service 
was rendered.. Therefore, we decided that the Plan does not have to pay for the manual therapy (97139) 
provided on August 6, 2020, through December 14, 2020.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours of therapy per 
day at least 5 days per week, or 15 hours over 7 consecutive days, of therapy services. It is not clear that the 
enrollee is reasonably expected 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on July 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that there has been a misinterpretation of guidelines. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim information lists a place of service as an independent laboratory. 
If an independent lab bills for services, the place where the sample was taken is reported as the POS. In this 
case, the records do not show that the specimen at issue was obtained at the independent laboratory. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing provided on July 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (ferric carboxymaltose) injections. 
 
You asked the Plan to pre-approve the Injectafer. You say that the requested drug is needed. The Plan denied 
your request. The Plan says there are preferred brands of iron supplementation that must be trialed prior to 
approving Injectafer. 
 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 the Injectafer. Our reviewer says that 
the requested medication is not considered reasonable and necessary based on step therapy guidelines. Our 
physician reviewer found the record indicates that the enrollee has iron deficiency anemia. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would 
have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are 
not satisfied.  
 
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 Injectafer have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer (ferric carboxymaltose) injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation services 
(A0427, A0425) provided on May 12, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you disagree with how 
this claim was processed. The Plan denied your request. The Plan says this claim was processed correctly, and 
your copayment was assessed in accordance with your contract. The services are covered, and you are 
responsible for a $290 copayment for ground ambulance services. 
 
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 $290 
copayment for ground ambulance transportation.  
 
 You have been asked to pay a $290 copayment for the ambulance transport. 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 the ambulance transportation services (A0427, A0425) provided on May 12, 2021.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found your functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. You are not fully participating in 
therapies per documentation. You do not require skilled nursing or skilled therapy services, or a combination of 
these services, on a daily basis in a SNF. As a practical matter, you do not require the necessary services on 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.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found your functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing 
or skilled therapy services, or a combination of these services, on a daily basis in a SNF. As a practical matter, 
you do not require the necessary services on 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interpretation of a computed tomography (CT) scan of the 
orbit/fossa/ears provided on September 30, 2021, billed with code 70480. 
 
You asked the Plan to pay for the CT interpretation. You say that it is felt that this should be paid. The Plan 
denied your request. The Plan says this was not billed with an appropriate modifier. 
 
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 interpretation of a computed tomography (CT) scan of the 
orbit/fossa/ears provided on September 30, 2021, billed with code 70480.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of lower back with 
contrast. 
 
You asked the Plan to pre-approve CT scan services. You say that a CT scan is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage of a CT scan have not been 
met. 
 
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 CT scan services. Our reviewer says 
that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found the record 
indicates that the enrollee has back pain.  The record does not indicate that the enrollee has had a plain film or 
undergone conservative treatment including physical therapy.  The record indicates that a similar study has 
been approved. The provided records do not indicate the medical necessity or reasonableness, as defined by 
Medicare rules, of the requested service. 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 CT scan services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve computed tomography (CT) scan of lower back with contrast.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of the Vertiflex device (22869). 
 
You asked the Plan to pre-approve insertion of the Vertiflex device. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 insertion of the Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found he current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of the Vertiflex device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve insertion of the Vertiflex device (22869).