Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria 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 Leqvio. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Praluent or Repatha before they will approve the requested drug. In this case, the patient has not tried 
and failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that discharging the enrollee home would be 
unsafe. You say that the enrollee is dependent, and non-ambulatory without round the clock caregiver support. 
You also say that the requested services are medically necessary. The Plan denied your request. The Plan says 
the services you require including daily lab monitoring and assessment of fluid status, can safely be received at 
the current facility.  
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 admission. Our reviewer says that 
the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found you are not 
currently stable for transfer to a lower level of care. The provided documentation indicates that you continue to 
require skilled nursing services and complex medical care that can be provided at the current LTACH. The 
reviewer found that your functional improvement with skilled therapy has been minimal, and you continue to 
require total care. Therefore, the reviewer found that admission to a SNF for inpatient skilled services 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were billed correctly. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need more treatment before being 
discharged home. The Plan denied your request. The Plan says you have no skilled nursing needs and no daily 
skilled therapy needs. 
 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 physician reviewer 
found that you are at a contact guard assist for standing up and walking, standby assist for sitting, and 
supervision for in-room ambulation. You do not have documented skilled nursing or therapy needs. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
your 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76770-26) provided on 
November 7, 2021. You asked the Plan to pay for the ultrasound. You say that this is not a duplicate claim and should be paid. The 
Plan denied your request. The Plan says this is a duplicate of a previous claim which has already been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules also say that claims or claim lines that have been determined to 
be an exact duplicate are rejected.  
 
We looked at the file and Medicare rules. The documentation shows that the Plan has paid a previous claim for 
this same service billed with the same CPT code and modifier for the same enrollee on the same date of service 
by the same provider has already been paid. The documentation does not support that the enrollee had two 
retroperitoneal ultrasounds on the date in question. Therefore, we decided that the Plan does not have to pay for 
the retroperitoneal ultrasound (76770-26) provided on November 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia services (D9222 and 
D9223) provided on December 8, 2021. 
 
You asked the Plan to pay for the deep sedation/general anesthesia services. You say that you had to have 
sedation for your tooth removals so you could be still during the procedure so the doctors could remove them 
appropriately. You also say that you could not have undergone this surgery awake for the fear and pain it 
would result in. The Plan denied your request. The Plan says these services are not covered benefits under your 
dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the deep 
sedation/general anesthesia services (D9222 and D9223) provided on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis B testing rendered on August 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 
pay for the Hepatitis B testing rendered on August 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits (97164). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary The Plan denied your request. The Plan says the requested additional PT visits do not meet 
criteria. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollee's medical 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve eight (8) additional physical therapy (PT) visits (97164).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the Vertiflex procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the Vertiflex device is 
experimental. More research is 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 pre-approve the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is not medically reasonable and 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
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 care. You say that SNF care is medically necessary for your condition. 
The Plan denied your request. The Plan says rules for SNF care have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the documentation provided, you do 
not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have 
documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your 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 SNF care 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: 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. The Plan denied your request. The Plan says the 
enrollee's needs can be provided at a lower level of care. 
 
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 physician 
reviewer found that in this case, the enrollee was admitted to the acute hospital with sepsis secondary to 
cellulitis. He has had a complicated hospital course including a massive gastrointestinal bleed. The record 
indicates he was discharged home but returned later that day as a home discharge plan was not feasible. The 
record indicates that the prior discharge recommendation was for a rehabilitation facility and does not indicate 
that he has additional acute care needs. The enrollee continues to receive acute care services and the record 
indicates that he requires rehabilitation services. These have not been denied and can be continued until 
appropriate discharge plans are made. The medical record does not indicate that the enrollee requires services 
that he is not currently receiving but that would be available at the LTACH facility. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-rays and tooth extraction rendered on July 
21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one 
panoramic or full mouth x-ray every five years and two tooth extractions every year. 
 
We looked at the file and the Plan's rules. The file shows that you previously received complete x-rays on June 
24, 2021 that the Plan covered. The panoramic x-rays performed on July 21, 2021 were performed less than 
five years from your previously covered x-rays. The file shows that you received three tooth extractions on July 
21, 2021. The Plan covers two extractions per year. The third extraction exceeds the benefit limit and was not 
covered. Based on this information, we decided that the Plan's rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the panoramic x-rays and tooth 
extraction rendered on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroelectrode implantation (64561) and insertion/redo 
gastric stimulator (64590) for the enrollee. 
 You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no record that the enrollee has had a successful test 
stimulation to support subsequent implantation. 
 
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 requested services are not considered medically reasonable and necessary in this case. There is no record 
that of a successful test stimulation to support subsequent implantation. The enrollee did not have adequate 
response 50% or greater improvement with a trial of this type of treatment. Our physician reviewer found that 
the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neuroelectrode implantation (64561) and insertion/redo gastric stimulator (64590) for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve an ESI. You say that you have been exercising at home during the pandemic 
as your wife is severely immunocompromised. You say that these injections are very helpful for you. You also 
say that without them, you may soon not be able to walk and require surgery. The Plan denied your request. 
The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that it generally would not be considered medically 
reasonable and necessary for treatment with ESI to extend beyond 12 months. 
 
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 an ESI. Our reviewer says that an 
additional ESI does not meet the criteria for coverage. Our physician reviewer found the record shows that the 
request for a 5th epidural steroid injection within a 12 month rolling period exceeds the utilization criteria. 
Therefore, at that time this request was made, an additional ESI was 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 an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete 
intraoral x-rays (D0210) and panoramic radiographic imaging (D0330) provided on October 26, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation, complete itraoral x-rays and panoramic 
radiographic imaging. You say that you would like reconsideration because you requested that the dentist not 
perform these services as you knew they would not be covered. The Plan denied your request. The Plan says 
you have exceeded the frequency limitation. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are covered, but the record indicates that you have exhausted the benefits for these services. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete intraoral x-rays 
(D0210) and panoramic radiographic imaging (D0330) provided on October 26, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and a computed tomography 
of the thorax  provided on July 27, 2021. 
You asked the Plan to waive the copayment for an office visit and a computed tomography of the thorax. You 
say that all of your doctors are in-network, and they said everything would be covered. You also say that you 
are on a very strict budget and cannot afford these bills and they are adding up. The Plan denied your request. 
The Plan says you were charged the correct cost sharing amount. 
 
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 $160 
copayment for computed tomography (CT) scans, and a $35 copayment for physician specialist services 
(including surgery second opinion, telehealth, and urgently needed services).  
 
You have been asked to pay $90, which is less than the $160 copayment for a computed tomography of the 
thorax. A computed tomography of the thorax falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. You have also been asked to pay a $35 copayment for an office visit. An 
office visit 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 an office visit and a computed tomography of the thorax  
provided on July 27, 2021.