Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for sacroiliac joint 
(64625). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee has had previous SI joint RFA with 80% 
relief for greater than 6 months. You also say that this is medically necessary for the enrollee. The Plan denied 
your request. The Plan says the requested service 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 the RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested RFA for sacroiliac joint is considered experimental and investigational. Therefore, the 
reviewer found that the requested service is 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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) for sacroiliac joint (64625).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 27, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. There 
was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on June 27, 2022.
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 ongoing therapy to be able to 
regain prior mobility and return home. The Plan denied your request. The Plan says the enrollee's needs can 
and are being met at a lower level of care. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided on July 4, 2021. 
 
You asked the Plan to pay for initial hospital care. The Plan denied your request. The Plan says Medicare 
denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year 
from the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for initial hospital care was not filed until October 19, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for initial hospital care provided on July 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tuberculosis test (86480) provided on June 7, 2022. 
 
You asked the Plan to pay for a tuberculosis test. You say that you disagree with the denial of this test. The 
Plan denied your request. The Plan says the services are not authorized because tuberculosis testing as 
screening for respiratory tuberculosis is not a covered benefit. These services were provided in the absence of 
signs, symptoms, complaints or personal history of a disease or injury. There is no documentation of a medical 
diagnosis for which this testing may be done, either on the claim form or in the available documentation. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a tuberculosis test, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a 
tuberculosis test (86480) provided on June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound/skin/soft tissue infection panel provided on July 
14, 2022. 
 
You asked the Plan to pay for the wound/skin/soft tissue infection panel. You say that the wound/skin/soft 
tissue infection panel provided on July 14, 2022, was medically necessary. The Plan denied your request. The 
Plan says the enrollee did not meet criteria for the provided wound/skin/soft tissue infection panel provided on 
July 14, 2022. 
 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 wound/skin/soft tissue infection panel. 
Our reviewer says that the enrollee did not meet criteria for the provided wound/skin/soft tissue infection panel 
provided on July 14, 2022. Our physician reviewer found there was no specific clinical rationale for the 
requested laboratory test. The literature states that wound healing genes whose expression are found to be 
increased late were the integrins av and 5. The integrin av is important in angiogenesis, fibroblast migration 
and wound closure. av5 is a receptor for vitronectin and av3 is a receptor for both fibronectin and 
vitronectin. Medicare does not provide specific coverage criteria for molecular syndromic panels for wound 
pathogen panels as this test is not deemed to have approvable clinical scenarios and current outcome studies 
from use of these panels is limited. The review has determined that the enrollee did not meet the above LCD 
criteria for the provided wound/skin/soft tissue infection panel provided on July 14, 2022. 
 
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 wound/skin/soft tissue infection panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the wound/skin/soft tissue infection panel provided on July 14, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on June 11, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says there is no order for the items rendered. 
 
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 a valid physician order for the supplies provided in this case. Review of the file 
shows that outreach was made to the ordering provider's office and was confirmed that the items were not 
ordered. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided 
on June 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (85014, 81015, 82947, 83986, 85018, 
85049, 81000, 81003, 85025, 36415, 86001, 89060, 83036, 84439, 80050, 82746, 84443, 84481, 81001, 87088, 
82542, 82306, 85027) provided on August 21, 2020. 
 
You asked the Plan to pay for laboratory services. You say that the claim was processed as out-of-network and 
charges were applied to the enrollee's responsibility. The Plan denied your request. The Plan says Medicare 
denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year 
from the date the services were furnished. The claim was received on 06/15/2022. This is past the allowed 12-
month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for laboratory services was not filed until June 15, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for laboratory services (85014, 81015, 82947, 83986, 85018, 85049, 81000, 
81003, 85025, 36415, 86001, 89060, 83036, 84439, 80050, 82746, 84443, 84481, 81001, 87088, 82542, 82306, 
85027) provided on August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dentures (CPT code(s): D5110 and D5120). 
 
You asked the Plan to pre-approve the dentures. You say that you received upper complete and lower dentures 
on April 11, 2022, and you went back two (2) times to get them adjusted without success. The Plan denied your 
request. The Plan says you have exhausted your denture benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Review of the records indicate that you received upper and lower immediate dentures on April 11, 2022. Your 
2023 EOC states that complete dentures (upper and lower) or Partial dentures (upper and lower) (1 upper 
complete/partial and/or 1 lower complete/partial denture every 5 calendar years, including routine post-delivery 
care) Includes necessary extractions to fit dentures (unlimited). Therefore, you have exhausted your benefit. 
Therefore, we decided that the Plan does not have to pre-approve the dentures (CPT code(s): D5110 and 
D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01992) provided on July 7, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 01992 is not supported in the medical record. Specifically, the diagnosis code billed 
(M54.16) is not listed as a supporting diagnosis for monitored anesthesia care per Local Coverage Article: 
Billing and Coding: Monitored Anesthesia Care (A57361). Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (01992) provided on July 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from skilled nursing 
facility (SNF) care and the services would help with the improvement of enrollee's condition if approved. The 
Plan denied your request. The Plan says there is no documentation of daily intense and complex care needs 
which would require a skilled nursing facility (SNF) level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee 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 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound/skin/soft tissue infection panel (87481, 87640, 
87651, 87653, and 87798) provided on June 22, 2022. You asked the Plan to pay for the wound infection panel. You say that this testing was medically necessary and 
was ordered by the enrollee's treating physician. The Plan denied your request. The Plan says this testing was 
not medically necessary and reasonable, as this panel is not FDA approved and has not met the necessary 
criteria for MolDX approval. 
 
The Plan must follow Medicare rules. Medicare rules say that services that do not have Food and Drug 
Administration (FDA)-cleared/approved indicated uses, as well as FDA-approved tests performed in ways not 
consistent with their intended-use labeling directions, will require registration with Molecular Diagnostic 
Services Program (MolDX) and a Technical Assessment (TA) to demonstrate compliance of the service with 
this policy. 
 
We looked at the file and Medicare rules. This panel is not FDA approved, nor is it approved and covered 
according to the MolDX program. Based on this information, we decided that Medicare rules for coverage of 
the wound infection panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
wound/skin/soft tissue infection panel (87481, 87640, 87651, 87653, and 87798) provided on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Group 3 power wheelchair coded with CPT codes 
K0856, E2361, E1002, E2620, E0955, E1028, K0040 and E2605. 
 You asked the Plan to pre-approve the power wheelchair. You say that you are appealing the denial for the 
power wheelchair. The Plan denied your request. The Plan says the enrollee does not have medical need for 
single power option included with K0856 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a Group 3 qualifying diagnosis of a myopathy. The documentation 
indicates the enrollee has a mobility deficit that impairs some MRADLs in the home and cannot be overcome 
with a manual wheelchair, walker, or cane due to weakness and safety issues. While the enrollee may be able to 
safely use the requested wheelchair the documentation does not reveal that the requested chair with multiple 
power options is medically necessary. The documentation does not reveal that the enrollee uses a ventilator 
attached to a wheelchair, is at high risk for development of a pressure ulcer. There is no evidence of 
intermittent catheterization. The physician documentation does not indicate objective evidence of spasticity on 
a physical exam that needs a power seating system for management therefore the request for power tilt and 
recline exceeds the enrollees medical needs. The enrollee does not require a ventilator attached to the 
wheelchair. The request for a Group 3 power wheelchair with power tilt exceeds the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Group 3 power wheelchair coded with CPT codes K0856, E2361, E1002, E2620, 
E0955, E1028, K0040 and E2605.
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 services are medically necessary for the enrollee 
to help get their strength and endurance back. The Plan denied your request. The Plan says the enrollee can 
safely receive the services needed in another setting, such as a skilled nursing facility, home with home health 
and home physical therapy. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record does support a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has Crohn's disease. He has 
not tried and failed the Plan's required drugs, Remicade, Inflectra, or Infliximab and Stelara. The records report 
a concern with the use of Remicade, Inflectra, or Infliximab due to a history of asthma; however, the records do 
not show that Stelara would be contraindicated or less effective. Entyvio is 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 Entyvio.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 16, 2022, to 
July 13, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says an NOA (Bill Type 32A) has not been submitted. 
 
The Plan follows Medicare rules. The rules say that HHAs shall no longer submit RAPS (Type of Bill 0322) 
for any HH period of care with a From date on or after January 1, 2022. Instead, for each admission to home 
health, the HHA notifies Medicare systems via submission of an NOA.  
 
We reviewed the file and the Medicare rules. We find that an NOA with the correct Type of Bill (32A) has not 
been submitted. Based on this information, we find that the Medicare rules for payment of the claim at issue 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from June 16, 2022, to July 13, 2022.