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

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion surgery. 
 
You asked the Plan to pre-approve sacroiliac joint fusion surgery. You say that the requested procedure is 
medically necessary, as the enrollee's pain level has been severe. You say that the enrollee has been doing an 
ongoing home exercise program and has had several injections over the years, without significant relief. The 
Plan denied your request. The Plan says the records show that the enrollee has had confirmation of sacroiliac 
joint etiology via pain relief of at least 50% from needle injection of local anesthetic into the left sacroiliac 
joint. The Plan says that the records do not show a failure to respond to a sacroiliac joint steroid injection, 
physical therapy, or a radiofrequency rhizotomy for the left sacroiliac joint pain. The Plan says that the 
requested procedure is not 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 pre-approve sacroiliac joint fusion surgery. Our 
reviewer says that sacroiliac joint fusion surgery is not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding a left-sided sacroiliac joint 
injection that provided at least 75% to corroborate the pain generator. Additionally, other plausible pain generators have not been ruled out. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac joint fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for services provided on June 
23, 2022. 
 
You asked the Plan to pay for procedure code 99204. The Plan denied your request. The Plan says there are no 
modifiers allowed with this code pair. 
 
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 99204 is a column II code to column I code 99205 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99204 
billed for services provided on June 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 12, 2022, to 
April 6, 2022. 
 
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied 
your request. The Plan says this was not billed with a date of admission that matches the NOA. 
 
The Plan must follow Medicare rules. Medicare rules say that for all beneficiaries receiving home health 
services in 2021 whose services will continue in 2022, the home health agency (HHA) shall submit a Notice of 
Admission (NOA) with a one-time, artificial 'admission' date corresponding to the "From" date of the first period of continuing care in 2022. The HHA should submit the same admission date on all subsequent claims 
until the beneficiary is discharged and another NOA is required. 
 
We looked at the file and Medicare rules. The record shows that the final claim was not submitted with the 
same admission date as the NOA. Based on this information, we decided that Medicare rules for coverage of 
home health services have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services provided from March 12, 2022, to April 6, 2022.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the 
current acute setting. The Plan says that LTACH care would not add additional services. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. 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. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis.  
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 procedure codes 88341, 88342, and 88360, billed for date of 
service March 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was billed correctly. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
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 services at issue were not billed with a modifier suitable for payment.  
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88360, 
billed for date of service March 16, 2022.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 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 Plan. The Plan has approved ongoing care in the current 
acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Inogen G5 portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the Inogen G5 portable concentrator. You say that the enrollee has a 
medical necessity for a lightweight portable oxygen concentrator less than 2 pounds due to several physical 
limitations and risk for falls. The Plan denied your request. The Plan says the standard plan offered portable 
oxygen concentrator was approved. There is no medical necessity, superior benefit or indication to support the 
brand specific item that was requested. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary.  
The file shows that the enrollee has portable oxygen concentrator coded as E1392. The Plan approved portable 
oxygen concentrator serves the same purpose as the Inogen G5 portable concentrator. Therefore, we decided 
that the Plan does not have to pre-approve the Inogen G5 portable oxygen concentrator (E1392).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from March 21, 2022, through March 31, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the inpatient skilled nursing facility care 
provided was 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 pay for the SNF care. Our reviewer says that the 
SNF care provided was not medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found that daily skilled services were not required from March 21, 2022 through March 31, 2022. The 
enrollee was walking household distances with a front wheeled walker with contact guard assistance and was 
stand-by assist for transfers and supervision for most activities of daily living (except moderate assist for 
bathing). Additionally, as a practical matter, this enrollee did not require the services on an inpatient basis, only 
in a skilled nursing facility setting. The services provided in the nursing facility appear custodial in this case 
with part-time therapy services provided. 
 
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 care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient skilled nursing facility (SNF) care provided from March 21, 2022, through  
March 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service August 10, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 procedure code 76700 billed for date of service August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
May 23, 2022. 
 You asked the Plan to pay for procedure codes 88341 and 88342. The Plan denied your request. The Plan says 
payment for codes 88341 and 88342 are bundled into payment for code 88360. 
 
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 codes 88341 and 88342 are column II codes to column I code 88360. The 
codes at issue have 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 procedure codes 88341 and 88342 billed for date of service May 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy evaluations provided on 
May 24, 2022, to July 28, 2022. 
 
You asked the Plan to waive the copayments for the physical therapy evaluations. You say that you cannot pay 
the bill to the provider. 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 $30 
copayment for Medicare-covered physical therapy in-person visits.  
 
You have been asked to pay a total of $450 ($30 x 15 visits = $450). Physical therapy evaluations fall within 
the outpatient rehabilitation 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 copayments for 
physical therapy evaluations provided on May 24, 2022, to July 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of recurrent 
and progressive metastatic bronchogenic adenocarcinoma. The Food and Drug Administration (FDA) has not 
stated that the requested drug is indicated for the enrollee's specific condition. The Medicare-approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's specific 
clinical situation. 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tecentriq.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for spinal 
stenosis of the lumbar region with neurogenic claudication. Current evidence-based medical guideline and 
peer-reviewed literature do not fully support the spinal Coflex interlaminar/interspinous device procedure 
over/beyond the gold standard of lumbar laminectomy. There is a lack of large-volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. The services 
are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coflex spacer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Rituxan. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has rheumatoid arthritis. The documentation does not support that the enrollee has tried and 
failed Remicade, Inflectra, Infliximab, or Simponi Aria. The documentation does not support that Remicade, 
Inflectra, Infliximab, or Simponi Aria would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a thyroidectomy provided on June 15, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the thyroidectomy. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 thyroidectomy provided on June 15, 2021, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that the doctor recommended you switching the loop 
because you have had it since 2016. The Plan denied your request. The Plan says the services are not 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 ILR. Our physician reviewer found 
while you have a history of atrial fibrillation, there is no documentation provided to suggest a history of 
unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ILR in your clinical 
management.  
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ILR (CPT code 33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you request a 
full and fair review of all the compelling clinical information submitted which will clearly demonstrate the 
clinical reasons for excluding a simple leg pump as ineffective. The Plan denied your request. The Plan says 
the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week 
trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0667, E0656).