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

 
We decided that the Plan does not have to pre-approve the injection of sclerosant; multiple incompetent veins 
(other than telangiectasia), same leg (36471). 
 
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is no new information in the appeal that would demonstrate treatment 
of great saphenous vein (GSV) reflux nor document tributary size greater than 4 millimeters (mm). 
 
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 injection. Our physician reviewer 
found the treatments of the tributary veins will be considered medically necessary if saphenous reflux is not 
present or already successfully eliminated, the veins are greater than 4 mm in diameter and if the patient 
remains symptomatic after a six-week trial of conservative therapy. The components of the conservative 
therapy include, but are not limited to: weight reduction, a daily exercise plan, periodic leg elevation, and the 
use of graduated compression stockings. The documentation does not sufficiently support that there has been a 
a six-week trial of conservative therapy.  
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg 
(36471).
Appeal type: Drugs
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 the requested Leqvio is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail a PCSK9 inhibitor, such as Repatha, first. 
 
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 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has Mixed hyperlipidemia. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services (97802) provided on 
January 11, 2022. 
 
You asked the Plan to pay for the medical nutrition therapy services. You say that you would like this to be 
reviewed and considered for reprocessing. The Plan denied your request. The Plan says this service is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy services (97802) provided on January 11, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve MRI of the cervical spine (72141) and left shoulder (73221). 
We decided that the Plan does not have pre-approve an MRI for the left upper extremity (73218). 
 
You asked the Plan to pre-approve the MRIs. You say that your numbness is getting worse, and your physician 
recommends these services. The Plan denied your request. The Plan says that the requested MRI are not 
medically necessary at this time. 
 
  We decided that the Plan has to pre-approve MRI of the cervical spine (72141) and left shoulder (73221).  
 
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 the MRIs. Our reviewer says that the 
request for MRI of the cervical spine and left shoulder are medically necessary. Our physician reviewer found 
you had a three-week course of physical therapy which was halted due to pain and the advice of the therapist. 
You had a non-diagnostic nerve conduction study. Your reflexes are normal. X-rays show multilevel 
degenerative changes of the cervical spine and importantly her left shoulder series showed a high riding 
humeral head which is strong evidence of a rotator cuff tear.  Given these facts the MRI of the cervical spine 
and left shoulder should be approved. Therefore, we decided that the Plan has to pre-approve MRI of the 
cervical spine (72141) and left shoulder (73221).  
 
We also decided that the Plan does not have to pre-approve MRI for the left upper extremity (73218). 
 
There is no documented reason on clinical grounds for the MRI of the left upper extremity. Therefore, we 
decided that the Plan does not have to pre-approve MRI for the left upper extremity (73218). 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit provided 
from July 21, 2022, to July 23, 2022. 
 
You asked the Plan to waive the copayment for the emergency department visit. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for emergency care. 
 
You have been asked to pay a $35 copayment for the emergency department visit. This 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. Therefore, we decided that the Plan does not have to waive the copayment for an emergency department 
visit provided from July 21, 2022, to July 23, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on September 23, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that additional information is required to 
consider this 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. Specifically, the requested documentation has been provided since the initial 
denial. The Plan has not provided an updated reason for denial in this case, and this reason has not been 
supported with evidence and a relevant citation. Therefore, we decided that the Plan has to pay for laboratory 
services provided on September 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 28, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says treatment for thickened toenails would be considered routine foot care 
and not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
physician's services have not been met. Therefore, we decided that the Plan does not have to pay for physician's 
services provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and psychotherapy provided on 
December 5, 2022. 
 
You asked the Plan to pay for the office visit and psychotherapy. The Plan denied your request. The Plan says 
except for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit and psychotherapy provided on December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 2, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 the pneumatic compression device provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) 
provided on January 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not agree that the provided service was 
not covered. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodic oral evaluation - established patient (D0120) provided on January 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 3, 2022, 
through August 13, 2022, and billed with diagnosis codes A41.51 and R65.20. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis code A41.51 and secondary diagnosis code R65.20 is supported by the records. The Plan denied your 
request. The Plan says the documentation submitted does not support primary diagnosis of A41.51 and 
secondary diagnosis of R65.20. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must 
report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and 
secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.51-sepisis due to E. coli and 
secondary diagnosis code R65.20--severe sepsis without septic shock. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation does not 
support the primary diagnosis code A41.51-sepisis due to E. coli and secondary diagnosis code R65.20--severe sepsis 
without septic shock. Our physician reviewer found the member presented with a fever and lethargy, in the setting of 
diabetes, end-stage renal disease, morbid obesity and decubiti. The member was treated for a urinary tract infection and 
chronic infectious diarrhea. There is no evidence of hypotension, hypo perfusion or acute organ failure to support a 
diagnosis of sepsis. As such, the billing of A41.51 and R65.20 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical 
records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital services provided on August 3, 2022, through August 13, 2022, and billed with diagnosis 
codes A41.51 and R65.20.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on August 17, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections. 
 
You asked the Plan to pre-approve the requested services. You say that radiofrequency ablation will be 
performed if medial branch blocks are successful. The Plan denied your request. The Plan says facet pathology 
could explain the enrollee's pain. 
 
The Plan follows Medicare rules. Medicare rules say that facet injections are only covered under certain 
medical indications.  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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain due to lumbar spondylosis, without myelopathy or 
radiculopathy. In this case, there is non-facet pathology that could explain the source of the enrollees pain. The 
review has determined that the requested treatment is not indicated for 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
enrollee does not meet the guidelines for care in an LTACH. 
 
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 improving but still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that they are 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 17, 2022, to 
February 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 17, 2022, to 
February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatments. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has low back pain with lumbar radicular pain. According to the coverage 
criteria, repeat ESI when the first injection directly and significantly provided improvement of the condition 
being treated, may be considered medically reasonable and necessary when the medical record documents at 
least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline 
using same scale for at least three months. In this case, the member has not had at least 50% pain relief and 
improved function for at least three months from the previous epidural steroid injection. It has only been 5 
weeks since the last epidural steroid injection. The review has determined that the requested treatment is not 
indicated for 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural steroid injection.