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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 75-year-old male being treated for vertebrogenic low back pain 
and other dorsalgia. He presented with low back pain. The pain is aching and burning. He feels that the 
injection did not alleviate his pain. The exam reveals bilateral paraspinal musculature tenderness to palpation. 
There is bilateral gluteal musculature tenderness to palpation. Facet loading is positive to extension. The 
lumbar spine range of motion is grossly intact with pain. Strength, sensation, and reflexes are intact. 
 
In this case, there were/are multiple plausible pathologic sources of significant pain generation. The aching and burning back pain, the noted pain-aggravating factors, the painful spinal motion (in all directions) and the intact 
neurologic exam were/are all non-specific to any pathologic entities. Overall, documentation was/is lacking 
regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support 
actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the drequested Intracept intraosseous 
basivertebral nerve ablation at L3 and L4, in this case, is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
ophthalmologist. 
 You asked the Plan to pre-approve a continuation of care with an OON ophthalmologist. You say that the OON 
provider quickly diagnosed him and started a treatment plan. The appellant says that he was diagnosed with 
Giant Cell Arteritis, which if not treated urgently can result in permanent blindness. The appellant says that he 
began seeing the requested OON ophthalmologist before joining the Plan. The Plan denied your request. The 
Plan says there are ophthalmologists in the network who are qualified to provide the care needed. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a continuation of care with an OON 
ophthalmologist. Our reviewer says that the criteria for coverage of OON care have not been met. Our 
physician reviewer found at the time of diagnosis, it does not appear visual acuity was significantly affected 
and treatment with prednisone was initiated.  Thus, the enrollee is stable and recommendation to follow-up in 1 
week with an in-network ophthalmologist is appropriate. There is nothing unique about the enrollee's condition 
that would make it medically necessary for him to continue care with the OON provider. The Plan has shown 
that they have in-network specialists who have the qualifications and expertise necessary to meet the current 
medical Standards of Care required for treatment of the enrollee's condition. The enrollee's medical 
management and follow-up care can safely be transitioned to an in-network specialist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuation of care with an OON ophthalmologist have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network 
(OON) ophthalmologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted socket system (VASS). 
 
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 had a recent replacement 
socket. The requested device has not been shown to be superior to other standard treatments for her medical 
condition. The VASS 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 a vacuum assisted socket system (VASS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on July 7, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. 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 $20 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $10 copayment which is less than the $20 copayment for office visit. This 
item/service falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on July 7, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Avsola. 
 
You asked the Plan to pre-approve Avsola. You say that you are already overdue for this drug. The Plan denied 
your request. The Plan says the Plan requires a trial of Remicade, influximab, or Inflectra before it will approve 
Avsola. 
 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 Avsola. Our reviewer says that you do 
not meet criteria for a step therapy exception for Avsola. Our physician reviewer found the documentation does 
not show that you have tried and failed the Plan's preferred drugs of Remicade, influximab, or Inflectra. The 
record does not show that these drugs are likely to be less effective and/or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avsola have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Avsola.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for luspatercept injections and Medicare-
covered diagnostic tests provided on February 11, 2022. 
 
You asked the Plan to waive the cost share for luspatercept injections and Medicare-covered diagnostic tests. 
You say that you are disputing the share cost. 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of these injections total $19,283.85, 
resulting in a total coinsurance amount of $3,856.77. You are responsible for $3,337.87, which is less than the 
$3,856.77. You must pay $30 copayment for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay 20% coinsurance for luspatercept injections and $30 copayment for Medicare-
covered diagnostic tests. This items/services fall within the Medicare Part B prescription drugs and 
outpatient diagnostic tests and therapeutic services and supplies benefit categories. 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 cost share for luspatercept injections and Medicare-covered diagnostic tests provided on February 
11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency service provided on July 9, 
2022. 
 
You asked the Plan to waive the copayment for emergency service. You say that you are disputing the share 
cost. 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 $90 
copayment for outpatient hospital services.  
 
You have been asked to pay $90 copayment for emergency service. This item/service falls within the outpatient 
hospital 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 copayment for emergency service 
provided on July 9, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for liquid biopsy testing you received on July 22, 2022. 
 
You asked the Plan to pay for the liquid biopsy testing. You say that you believed that this testing was 
authorized.  You said that this should be the lab's obligation because they shouldn't have performed this test if it 
wasn't authorized. The Plan denied your request. The Plan says that you do not meet policy criteria for 
coverage of liquid biopsy. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
According to the case file that the Plan submitted, the lab from which you received the liquid biopsy is a 
network provider. The file does not show that the Plan provided notice that the liquid biopsy testing would not 
be covered prior to these services being rendered.  As a network provider, the lab that provided these services 
should know which services are covered and which are not. Under Medicare rules, this means the liquid biopsy 
testing is considered approved by the Plan. Therefore, we decided that the Plan has to pay for liquid biopsy 
testing you received on July 22, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the LTACH services you are requesting do not meet 
the requirements for approval. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The Plan has approved ongoing care in the current acute care 
setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
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 service is medically necessary. The Plan denied 
your request. The Plan says the information they have do not show the enrollee has had a stroke or three or 
more fainting spells in the past two years. 
 
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 
there is insufficient documentation to support the medical necessity for insertion of an ILR in this enrollees 
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: 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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH 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 
there is no evidence that the enrollee requires services that are not currently available. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing LTC 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 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 a home ventilator. 
 
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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 was recently hospitalized 
with congestive heart failure and pulmonary edema. The arterial blood gas (ABG) results suggest the sample 
was probably venous rather than arterial, so there is no documentation of chronic carbon dioxide retention with 
ABG done while stable. There is no diagnosis of chronic obstructive pulmonary disease (COPD), restrictive 
thoracic disease, or neuromuscular disease. The ventilator 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 a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) provided on May 29, 2022. 
 
You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the date on the proof of delivery does not match the 
billed date of service. 
 
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 proof of delivery for the supplies provided in this case. Review of the file 
shows that the shipping date was May 23, 2022 and the delivery date was May 26, 2022. These dates do not 
match the billed date of service. 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 supply 
allowance for therapeutic continuous glucose monitor (CGM) provided on May 29, 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 services requested are medically 
necessary. The Plan denied your request. The Plan says the member does not meet the Medicare criteria for 
LTACH 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 the medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to a lower 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from March 6, 
2022, to April 4, 2022. 
 
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 this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 5, 2022. The NOA has an admit date of June 9, 2021. This is 
incorrect. Therefore, we decided that the Plan does not have to pay for home health services provided to the 
enrollee from March 6, 2022, to April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0483) provided on June 20, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service is supported as billed. The Plan denied 
your request. The Plan says this service is not supported in the medical record, and another code may be more 
appropriate to report the services provided. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers, 22 or more 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided only 
show that drugs from 12 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing services (G0483) provided on June 20, 2022.