Persius/hicric huggingface dataset:
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 would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee's needs can be met at an alternate 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 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 waive the cost sharing amount for the office visit provided on 
November 8, 2022. 
 You asked the Plan to waive the cost sharing amount for the office visit. You say that the enrollee went in for 
an annual wellness visit. You say that the enrollee should not be billed for an office visit when only an annual 
wellness visit was performed. You also say that you do not believe the enrollee should be responsible for this 
amount. 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 10% 
coinsurance for Doctor and other health care provider services. Your contract with the Plan says that there is an 
$800 annual deductible which applies to all covered medical services 
 
You have been asked to pay a coinsurance equal to 10% of the allowed amount for the office visit, as well as a 
portion of the deductible. This service falls within the Doctor and other health care provider services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a deductible which 
applies to the office visit. These cost sharing are a contractual obligation you agreed to pay when you enrolled 
in the Plan. Additionally, the file supports that services outside of an annual wellness exam were performed 
during the visit. Therefore, we decided that the Plan does not have to waive the cost sharing amount for the 
office visit provided on November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of a SPRINT peripheral 
nerve stimulator (PNS). 
 
You asked the Plan to pre-approve the percutaneous implantation of a SPRINT PNS.. You say that  the service 
is medically necessary for the enrollee's knee pain. The Plan denied your request. The Plan says  the 
percutaneous implantation of neurostimulator electrode array of a peripheral nerve is not medically necessary. 
 
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 percutaneous implantation of a 
SPRINT PNS. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was being treated for unilateral primary 
osteoarthritis of the right knee. However, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. There is no 
compelling rationale or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested SPRINT peripheral nerve stimulator (PNS), in this case, is 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 the percutaneous implantation of a SPRINT PNS. have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the percutaneous implantation of a SPRINT peripheral 
nerve stimulator (PNS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 20 and 22 
(D6740) and pontic - porcelain/ceramic tooth 21 (D6245). 
 
You asked the Plan to pre-approve the retainer crown - porcelain/ceramic and pontic - porcelain/ceramic. You 
say that these services are medically necessary. The Plan denied your request. The Plan says the submitted 
narrative fails to indicate or support any specific physical or psychological condition(s) that preclude the use of 
a removable prosthesis.  
 
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 Plan covers retainer crown - porcelain/ceramic and pontic - porcelain/ceramic when the services are 
medically necessary and reasonable.  
 
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 retainer crown - porcelain/ceramic and 
pontic - porcelain/ceramic. Our reviewer says that the dental services are not medically necessary. Our 
physician reviewer found the documentation indicates that tooth #20 is missing (not #21). The retainer crowns 
would be teeth #'s 19 and 21 (not #'s 20and 22). However, the incorrect teeth listed have no bearing on the 
decision since a posterior bridge is beyond the scope of the plan.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown - porcelain/ceramic and pontic - porcelain/ceramic have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic 
tooth #'s 20 and 22 (D6740) and pontic - porcelain/ceramic tooth 21 (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional counseling (99205). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the service is medically 
necessary. The Plan denied your request. The Plan says you do not have diabetes or a renal disease. 
 
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 you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve nutritional counseling (99205).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous basivertebral nerve ablation at 
L3. 
 
You asked the Plan to pre-approve an Intracept intraosseous basivertebral nerve ablation. You say that member 
has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says this 
procedure is not medically necessary. 
 
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 an Intracept intraosseous basivertebral nerve ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found overall, documentation was/is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. 
 
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 Intracept intraosseous basivertebral nerve ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an Intracept intraosseous basivertebral nerve 
ablation at L3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95908, 95927, 95937, 95955) provided on 
January 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 95927, 
95937, and 95955, is not supported by the records provided. Our reviewer found that the medical records 
provided do not include sufficient documentation to validate that "Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method" was performed January 27, 2021, therefore this 
procedure cannot be verified. The medical records indicate the Train-of-Four testing was performed, which is 
inclusive to intraoperative monitoring (IOM) and is not covered by the definition of CPT code 95937. The 
medical records provided do not include sufficient documentation to validate that a "Short-latency 
somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the 
central nervous system; in the trunk or head" was performed January 27, 2021, therefore this procedure cannot 
be verified. The medical records documented neurophysiology monitoring (IONM) documents the ulnar nerve 
was stimulated with recording at Erb's point. This is inclusive to the somatosensory evoked potential (SSEP) of 
the ulnar nerve and no additional reimbursement is allowed. The medical records provided do not include 
sufficient documentation to validate that an "Electroencephalogram (EEG) during nonintracranial surgery (eg, 
carotid surgery)" was performed January 27, 2021, therefore this procedure cannot be verified. The medical 
records provided documented a real time EEG, which is not covered by code definition of 95955. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 95927, 95937, and 95955, have not been met. 
 
In this case, we have also confirmed that code 95908 is a column II code to column I code 95861 with a 
modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services 
(95908, 95927, 95937, 95955) provided on January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed tomographic angiography (75635). 
 
You asked the Plan to pre-approve Computed tomographic angiography. The Plan denied your request. The 
Plan says the medical records do not show the enrollee demonstrates muscle pain in legs that happens when 
active and stops when at rest and has failed three months of conservative therapy such as a physician 
supervised walking/exercise program.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 Computed tomographic angiography. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there was no 
documentation provided describing failure of three months of conservative therapy such as a physician 
supervised walking/exercise program. This will be considered 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 Computed tomographic angiography have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Computed tomographic angiography (75635).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve atezolizumab (J9022) in combination with 
cyclophosphamide (J9070), doxorubicin hydrochloride (J9000), and vincristine sulfate (J9370). 
 
You asked the Plan to pre-approve the drug regimen. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the criteria has not been met for the use 
of the requested chemotherapy regimen.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the drug regimen. Our reviewer says 
that the requested drug regimen is not medically necessary, safe, and effective for the enrollee. Our physician reviewer found that the requested drug regimen of atezolizumab, cyclophosphamide, doxorubicin 
hydrochloride, and vincristine sulfate is not evidenced based and is not supported by any drug compendia or 
medical literature. 
 
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 drug regimen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve atezolizumab (J9022) in combination with cyclophosphamide (J9070), doxorubicin 
hydrochloride (J9000), and vincristine sulfate (J9370).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections in both knees. 
 
You asked the Plan to pre-approve Euflexxa injections in both knees. You say that the injections are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the recent notes did not discuss the last 
viscosupplementation and how you responded. Therefore, the request for Euflexxa cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa injection in both knees. Our 
reviewer says that the requested service cannot be recommended. Our physician reviewer found the record 
indicates that the enrollee received viscosupplementation injections in September 2022 and required 
corticosteroid injections in March and June 2023. The record provided does not document improvement from 
the previous viscosupplementation injection. The medical record provided is insufficient to establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service.  
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa injections in both knees have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Euflexxa injections in both knees.
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 the enrollee meets the Medicare criteria for IRF 
services and will benefit from IRF care that cannot be accomplished at a lower level of care. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 that 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 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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. There 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 15, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, the MolDX program 
requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are 
met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in 
the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service February 15, 2023.
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 is receiving the appropriate inpatient care and does not require transfer to a long-term acute care 
hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 October 11, 2022, to 
October 24, 2022. 
 You asked the Plan to pay for the home health services. You say that you do not believe there is any error in 
your billing. 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 7, 2022. The NOA was not received by the Plan until November 
18, 2022. 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 the home health services 
provided from October 11, 2022, to October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD test genetic panel provided on August 10, 
2022.  
 
You asked the Plan to pay for the AVISE CTD test genetic panel. The Plan denied your request. The Plan says 
this panel is considered experimental and investigational, as it is unproven to alter disease prognosis or 
treatment outcomes and has not been proven to be superior to alternative tests and measures of disease activity.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the AVISE CTD test genetic panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has spinal stenosis, Parkinson's disease with gait 
dysfunction, chronic back pain, and possible neurologic consequences of diabetes mellitus. The available 
records do not support the medical appropriateness nor necessity of the AVISE CTD test panel provided on 
August 10, 2022. 
 
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 AVISE CTD test genetic panel have not been met. Therefore, we decided 
that the Plan does not have to pay for the AVISE CTD test genetic panel provided on August 10, 2022.