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

 
We decided that the Plan does not have to pre-approve Inflectra. 
 
You asked the Plan to pre-approve Inflectra. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Inflectra. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found although the endoscopic appearance 
suggested active ulcerative colitis, available records do not support a fulminant picture nor failure to respond to 
conventional infliximab dosing to warrant at onset maximum Inflectra dose administration. While biologic 
therapy may be medically appropriate in the enrollee's setting, the medical necessity for ongoing high-dose 
Inflectra in lieu of conventional, FDA-approved dosing, is not apparent.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Inflectra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Inflectra.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
without contrast (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine without contrast. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lumbar spine without 
contrast. Our reviewer says that the service is not medically necessary. Our physician reviewer found medical 
necessity of the requested MRI has not been established and there is no documented contraindication to a 6-
week trial of conservative management including physical therapy and plain films of the lumbar spine. 
 
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 MRI of the lumbar spine without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
without contrast (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections. 
 
You asked the Plan to pre-approve platelet rich plasma injections. You say that platelet rich plasma injections 
are medically necessary. The Plan denied your request. The Plan says platelet rich plasma injection do not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 platelet rich plasma injections. Our 
reviewer says that the requested platelet rich plasma injections are not considered medically necessary. Our 
physician reviewer found that you have thigh pain diagnosed as hamstring tendinosis having tried and failed 
physical therapy and exercise. Platelet-rich plasma (PRP) treatment was requested. However, the Medicare 
LCD coverage criteria outlines the overall low-quality evidence available for this type of treatment. Also, there 
is insufficient high-quality evidence to support PRP injections for hamstring tendinosis to support this 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of platelet rich plasma injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve platelet rich plasma injections.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on December 14, 2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that the billing provider is appropriate. 
The Plan denied your request. The Plan says that this service needed to be filed on a facility claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for opioid treatment 
services provided on December 14, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 12, 2022, to 
November 10, 2022. 
 
You asked the Plan to pay for home health services. You say that the home health services were needed. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, 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 September 12, 2022. The NOA was not received by the Plan until February 
28, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 12, 2022, to November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health care from May 6, 2023-
forward. 
 
You asked the Plan to pre-approve inpatient behavioral health care. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavioral health care. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there was no 
indication in the available medical records that the enrollee's psychiatric symptoms could not be managed on a 
less restrictive basis. He was noted to have been accepted into an intensive outpatient program. The enrollee 
was not exhibiting any other significant symptoms such as suicidal ideation or mania. He had no acute 
psychiatric issues that would require continued inpatient care. The enrollee has chronic symptoms. The 
available medical records do not support that inpatient care would have changed these symptoms or the 
enrollee's current condition.  The enrollee is chronically delusional, and the continued inpatient hospital stay 
was not expected to improve the enrollee's condition in a reasonable period of time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient behavioral health care from May 6, 2023-forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 94729, 94010 and 94726 billed for date of 
service December 12, 2022. 
 
You asked the Plan to pay for procedure code(s) 94729, 94010 and 94726. You say that you believe these 
services were billed correctly. The Plan denied your request. The Plan says these codes are included in the 
facility payment and is not separately payable. You did not bill with the required modifier to allow for separate 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 94729, 94010 and 
94726. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 94729, 
94010 and 94726. Based on this information, we decided that Medicare rules for coverage of procedure code 
94729, 94010 and 94726 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 94729, 94010 and 94726 billed for date of service December 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more care than you are receiving in the 
skilled nursing facility. The Plan denied your request. The Plan says the service requested is not supported on 
the records received. 
 
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 that the clinical documentation shows you have active medical comorbidities and 
complex functional impairments. Thus, the complexity of your documented nursing, medical, and rehabilitation 
needs would be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Clinical documentation shows that you require ongoing physical therapy and occupational 
therapy but does not show that you would tolerate an intensive rehabilitation regimen in an IRF setting. Our 
reviewer found that IRF criteria are not met. 
 
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 an IRF admission and services.
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 enrollee requires LTACH level of 
care and if discharged to a lower level of care could result in a poor outcome including death. The Plan denied 
your request. The Plan says an LTACH admission is not medically necessary, and the enrollee's needs can be 
met in their current setting. 
 
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 that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88291, 88364, 88365, 88368, 88369, and 
88377 billed for date of service November 4, 2022. 
 
You asked the Plan to pay for procedure code 88291, 88364, 88365, 88368, 88369, and 88377. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
payment for codes 88291, 88364, 88365, 88368, 88369, and 88377 are bundled into payment for codes 81405, 
81403, 81347, and 81176. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
88291, 88364, 88365, 88368, 88369, and 88377 are column II codes to column I codes 81405, 81403, 81347, 
and 81176. This claim has not been billed with an appropriate modifier to bypass the edit. The -59 modifier is 
not supported as a separate and distinct procedural service. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
88291, 88364, 88365, 88368, 88369, and 88377 billed for date of service November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to noble metal (D6242) Tooth 
#9 and 10. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the request approved to 
help with the health of your mouth. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
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. This benefit includes the 
requested pontic - porcelain fused to noble metal (D6242) but is limited up to four units of fixed dentures per 
year, covered one per tooth per life. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have been pre-approved for pontic - porcelain fused to noble metal (D6242) Tooth #7 and 8 and 
retainer crown - porcelain fused to noble metal (D6752) Tooth #6 and 11. Although these are two different 
services, they fall within the same category in your Evidence of Coverage and are subject to the same 
frequency limitations. Therefore, these benefits have been exhausted as of the authorization dates March 15, 
2023, to June 13, 2023. Therefore, we decided that the Plan does not have to pre-approve pontic - porcelain 
fused to noble metal (D6242) Tooth #9 and 10.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12013 billed for date of service March 27, 
2022. 
 
You asked the Plan to pay for procedure code 12013. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 12013 is bundled into 
payment for code 26770. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 12013 
is a column II code to column I code 26770. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 12013 billed for date of service March 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 you are requesting reconsideration for the denial 
of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to an IRF. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 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 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 trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator (E1392). 
 
You asked the Plan to pay for a portable oxygen concentrator. You say that you needed this item for a vacation. 
The Plan denied your request. The Plan says this item is not covered for travel. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a portable oxygen concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the back surgery may be safely performed with a 48 hour observational 
stay. No admission is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.