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

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint nerves 
(64625). 
 
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint nerves. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not supported by research. 
 
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 radiofrequency ablation of the 
sacroiliac joint nerves. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this is considered an experimental procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the sacroiliac joint nerves have not been met. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint 
nerves (64625).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 1, 
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 all treatment records are needed. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the Cardio Genomic laboratory services met, but did not 
exceed, the enrollee's medical need, and was at least as beneficial as an existing and available medically 
appropriate alternative. The testing is not considered an accepted standard of medical practice for the diagnosis 
or treatment of the enrollee's condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on November 7, 2021. 
 
You asked the Plan to pay for the opioid treatment services. You say that these services should be covered. The 
Plan denied your request. The Plan says that your facility does not appear on the Medicare list of Opioid 
Treatment Program Providers. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers opioid treatment services when 
the provider is enrolled in Medicare, is certified by SAMHSA, and is accredited by an accrediting body.  The 
Plan's sole basis for denial is that your facility is not on the Medicare list of Opioid Treatment Program 
Providers.  However, we do not agree.  We were able to locate your facility in the SAMHSA Opioid Treatment 
Program Directory.  This directory shows your facility as being certified as of December 14, 2003. The Plan 
has provided no other argument for non-coverage, so we find that the Plan has not supported its denial. 
Therefore, we decided that the Plan has to pay for opioid treatment services provided on November 7, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says this request exceeds the maximum benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one-way routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
January 3, 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 the records submitted do not indicate that two separate services were performed/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 71045 is "Radiologic examination, chest; single view." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found a single chest x-ray was done on 
1/3/22. That exam was signed by two different radiologists - but it was the same exam. 
 
We looked at this coder's review, the file, and Medicare rules. 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 additional imaging services provided to the enrollee on January 3, 2022.
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) (K0553) provided December 2, 2021. 
 
You asked the Plan to pay for the CGM supply allowance. You say that you are requesting reconsideration as 
the services were medically necessary. The Plan denied your request. The Plan says the records do not support 
the billed 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, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, there is no delivery confirmation to validate the 
enrollee received the supplies. 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) (K0553) provided December 2, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for head injury and stroke and were transferred to skilled nursing. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF 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 Neupogen (J1442). 
 
You asked the Plan to pre-approve Neupogen. You say that the requested medication is the generic of the Plan's 
preferred medication. The Plan denied your request. The Plan says step therapy requirements have not been 
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 Neupogen. Our reviewer says that the 
requirements for coverage of Neupogen have not been met. Our physician reviewer found the Plan requires a 
trial of Zarxio (Filgrastim-sndz) before they will approve the requested drug. The case file does not contain 
documentation of trial and failure of Zarxio. It also does not support that Zarxio would likely be less effective 
or have adverse effects for the enrollee 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 Neupogen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neupogen (J1442).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on February 28, 2021. 
 
You asked the Plan to pay for the opioid treatment services. You say that these services should be covered. The 
Plan denied your request. The Plan says that your facility does not appear on the Medicare list of Opioid 
Treatment Program Providers. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers opioid treatment services when 
the provider is enrolled in Medicare, is certified by SAMHSA, and is accredited by an accrediting body.  The 
Plan's sole basis for denial is that your facility is not on the Medicare list of Opioid Treatment Program 
Providers.  However, we do not agree.  We were able to locate your facility in the SAMHSA Opioid Treatment 
Program Directory.  This directory shows your facility as being certified as of December 14, 2003. The Plan 
has provided no other argument for non-coverage, so we find that the Plan has not supported its denial. 
Therefore, we decided that the Plan has to pay for opioid treatment services provided on February 28, 2021.  
 
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 a gradient compression wrap, non-elastic, below knee, 
30-50 mm hg, each identified with code A6545. You asked the Plan to pre-approve a gradient compression wrap. You say that you are having a hard time 
walking with the swelling and being in so much pain. The doctor told you to wear the farrow wraps to alleviate 
the swelling and the pain. The other compression stockings that you have tried cut into your feet and legs 
causing red creases down your legs where the stockings are and causing constant pain.  The Plan denied your 
request. The Plan says the requested item does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve a gradient compression wrap, non-elastic, 
below knee, 30-50 mm hg, each identified with code A6545.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving the care he needs in the hospital 
where he is now and there is no need to transfer to the LTACH at this time. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on 
November 1, 2021. 
 
You asked the Plan to pay for the services. You say that medical records have been submitted to support 
medical necessity. The Plan denied your request. The Plan says all of the asked for details haven't been 
received. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that alternative laboratory or clinical tests to definitively diagnose 
the enrollee's disorder/identify the condition are unavailable or results are clearly equivocal, and that the results 
of the testing will directly impact treatment or management of the enrollee. For testing panels, including but not 
limited to, multiple genes or multiple conditions, and in cases where a tiered approach/method is clinically 
available, testing would be covered ONLY for the number of genes or test that are reasonable and necessary to 
establish a diagnosis. The Comprehensive Cardio Panel includes testing of 117 genes. It has not been 
demonstrated that this number of genes or tests is reasonable and necessary to establish a diagnosis. The 
documentation does not support that the genetic testing services provided on November 1, 2021 were medically 
reasonable and necessary for the enrollee 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing services provided to the enrollee on November 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says SNF admission is 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 pre-approve SNF services. Our reviewer says that 
SNF admission is not medically necessary. Our physician reviewer found there are no identifiable skilled 
nursing needs.  Although there are identifiable skilled therapy needs, these services are not required on a daily 
basis in a 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift (E0627) provided May 18, 2021. 
 
You asked the Plan to pay for the seat lift. You say that the seat lift was medically necessary. The Plan denied 
your request. The Plan says the provider is not enrolled in Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an 
unassigned claim), a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The furniture vendor is not a Medicare enrolled provider. There are 
network providers that are enrolled in Medicare available. Based on this information, we decided that Medicare 
rules for coverage of the seat lift have not been met. Therefore, we decided that the Plan does not have to pay 
for a seat lift (E0627) provided May 18, 2021.