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

 
We decided that the Plan does not have to pre-approve prostate artery embolization (37243). 
 
You asked the Plan to pre-approve prostate artery embolization. You say that this is the best treatment for the 
enrollee. The Plan denied your request. The Plan says this is experimental. 
 
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 prostate artery embolization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found prostate artery embolization is considered an experimental technique to treat 
symptomatic benign prostatic hyperplasia. It is not recommended outside of a clinical trial 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 prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization (37243).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Feraheme is 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 Feraheme.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genesight Psychotropic Panel (0345U). 
 
You asked the Plan to pre-approve the genetic testing. You say that the enrollee meets coverage criteria by 
virtue of meeting the criteria in Local Coverage Determination LCD (L38394) and Local Coverage Article (LCA) A58324. The Plan denied your request. The Plan says this testing does not meet the requirements for 
approval. 
 
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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the request is not medically necessary because the records show that the 
enrollee does not have multiple genes to be tested as the records only show single gene for Effexor. The review 
has determined that the medical records provided did not show that the testing was medically necessary and 
meet the requirements listed in the LCD for Medicare coverage. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Genesight Psychotropic Panel (0345U).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that you have arthritis in both knees and 
can barely walk. The Plan denied your request. The Plan says the requested procedure does not meet the 
necessary requirements for approval. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is the subject of ongoing clinical trials and is considered experimental/ 
investigational. Therefore, the request is deemed 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulation (PNS) system. 
 You asked the Plan to pre-approve a Sprint PNS. You say that the requested treatment is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested treatment is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist. 
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this 
peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Sprint peripheral nerve stimulation (PNS) system.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the hospital services reported under revenue code 0510 for the inpatient 
stay provided on July 25, 2023, to July 28, 2023. 
 
You asked the Plan to pay for inpatient hospital care. You say that services were provided within 24 hours of 
the admission and should be paid. The Plan denied your request. The Plan says that the outpatient clinic visit 
was provided by a clinic owned by the hospital and the services were related to the admission. Therefore, those 
clinic services cannot be included in revenue code 0510. 
 
The Plan must follow Medicare rules. Medicare rules say that the policy requires payment for certain outpatient 
services provided to a beneficiary on the date of an inpatient admission or during the 3 calendar days (or 1 
calendar day for a non-IPPS hospital) prior to the date of an inpatient admission to be bundled. 
 
We looked at the file and Medicare rules. We found that the Plan has incorrectly applied the rules in this case, 
and that the services billed under revenue code 0510 were correctly included in the inpatient claim and are 
payable. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have 
been met. Therefore, we decided that the Plan has to pay for the hospital services reported under revenue code 
0510 for the inpatient stay provided on July 25, 2023, to July 28, 2023.  
 
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 services are medically 
necessary. The Plan denied your request. The Plan says the enrollee is stable and LTACH  services are not 
medically necessary. 
 
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 acute hospital can provide all the enrollee's present inpatient needs and they are 
receiving appropriate care in the present setting being provided by the health Plan. Continued care in the short-
term acute hospital is appropriate until they are stable for transfer 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth consultation provided on April 28, 2023, to 
May 02, 2023. 
 
You asked the Plan to pay for the telehealth consultation. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the telehealth 
consultation provided on April 28, 2023, to May 02, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for emergency-department care from July 30, 
2023, to August 2, 2023. The Plan does not have to pay for self-administered drugs. 
 
You asked the Plan to waive the cost-sharing for emergency-department care and to pay for self-administered 
drugs. You say that the hospital made an error in your registration and admission. The Plan denied your 
request. The Plan says the cost sharing for emergency-department care was charged correctly. The Plan says 
that the self-administered medications are not covered as a medical benefit under the Plan. 
 
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 $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for emergency-department care. This item/service falls within 
the emergency care 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. 
 
The rules also say that Medicare Part B generally does not pay for self-administered drugs. The drugs requested 
here are noted to be self-administered drugs and not among the types which are covered by Medicare Part B.  
 
Therefore, we decided that the Plan does not have to waive the cost-sharing for emergency-department care 
from July 30, 2023, to August 2, 2023. The Plan does not have to pay for self-administered drugs.
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 prefer to admit to acute rehabilitation because 
you were independent and active before coming to the hospital and wish to return to being independent as 
quickly as possible. The Plan denied your request. The Plan says you are medically stable, do not have complex 
rehabilitation, medical, and nursing needs. The Plan says services may be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records 
support 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. It 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.  
 
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: 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 LTACH services are necessary. The Plan 
denied your request. The Plan says the coverage criteria for an LTACH admission has not been met. 
 
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 enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has memory loss in the setting history of traumatic brain injuries. The record provided does not establish that 
the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal dementia or that the 
examination is being requested in the context of a clinical trial. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is now eligible to be transferred in order 
to get back to normal quality of life that the acute care would be the most beneficial. The Plan denied your 
request. The Plan says the enrollee does not have acutely complex rehabilitation and medical needs. The Plan 
says services may be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support 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. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from May 23, 2023, to June 19, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that the services at issue were provided by a non-participating 
provider. 
 
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. Specifically, we find that the home healthcare provider at issue is enrolled in the 
Medicare program. The Plan has not provided any other rationale for denial. It is the Plan's responsibility to 
support its denial with evidence. In this case, the Plan's denial is not supported, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for home health services provided from May 23, 2023, to June 
19, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service July 30, 
2023. 
 
You asked the Plan to pay for procedure code 99051. The Plan denied your request. The Plan says procedure 
code 99051 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99051 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service July 30, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve PsychPainMarkers Pharmacogenomic Panel. 
 
You asked the Plan to pre-approve PsychPainMarkers Pharmacogenomic Panel. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says that the requested services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that certain tests are covered under the MolDX 
program. 
 
We looked at the file and Medicare rules. Review of the file shows that the Plan states that the 
PsychPainMarkers panel is not covered. However, the DEX Diagnostics Exchange Registry states this testing 
is covered. No other denial rationale was provided. The Plan did not substantiate their denial. Based on this 
information, we decided that Medicare rules for coverage of PsychPainMarkers Pharmacogenomic Panel have 
been met. Therefore, we decided that the Plan has to pre-approve PsychPainMarkers Pharmacogenomic Panel.  
 
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.