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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation does not show that the enrollee would be expected to 
require daily skilled services on an inpatient basis in a skilled nursing facility; thus, SNF care is not medically 
necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 had surgery on a broken femur and have other 
medical issues and need to be receiving therapy to get back up where you were. The Plan denied your request. 
The Plan says your records do not show that you need an intensive team for your care. Services needed may be 
provided safely in 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0656, E0667, 
E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device . You say that this device was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0656, E0667, E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for the sports physical exam provided on  
August 4, 2022. 
 
You asked the Plan to pay for the office visit for the sports physical exam. You say that you needed this exam 
to be eligible to go to Boy Scout Camp. The Plan denied your request. The Plan says this is a non-covered 
benefit. 
 
The Plan contract says physical exams for employment, licensing, insurance coverage (i.e., pilot licenses, 
commercial driver license, etc.) are not covered under any condition. 
 
We looked at the file and the Plans rules. The file shows that a physical exam for employment, licensing, 
insurance coverage (i.e., pilot licenses, commercial driver license, etc.) is excluded from coverage. Therefore, 
we decided that the Plan does not have to pay for an office visit for the sports physical exam provided on  
August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service October 6, 
2022. 
 
You asked the Plan to pay for procedure code 97010. The Plan denied your request. The Plan says procedure 
code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says the 
radiofrequency ablation 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 the procedure. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that there is no documentation 
as to the degree and duration of the prior radiofrequency ablation (RFA). Therefore, the request fails to meet 
the LCD requirements and is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array, epidural (63650) to be provided at an out-of-network (OON) ambulatory surgical center. 
 
You asked the Plan to pre-approve an implantation of neurostimulator electrode array. You say that you 
disagree with the denial and request reconsideration. The Plan denied your request. The Plan says the enrollee 
has an HMO (Health Maintenance Organization) plan. The enrollee must use network providers/facilities for 
most services. There are in-network provider(s)/facilities within a reasonable distance from the enrollee's 
location that can provide this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a percutaneous implantation of neurostimulator electrode array, epidural (63650) to be provided at an out-of-
network (OON) ambulatory surgical center.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 You asked the Plan to pre-approve Entyvio. You say that the safety profile for Entyvio makes it the best choice 
for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed conventional 
therapy, nor the preferred drugs, Inflectra or Avsola. 
 
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 Entyvio. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee has tried and failed either of the preferred drugs, Inflectra or Avsola. The reviewer also found that 
there is no documentation provided indicating that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria 
have not been 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
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 your legs are swollen, unable to walk or move 
around and not able to be discharged home in current condition. The Plan denied your request. The Plan says 
your records do not show that you have a complex rehabilitation need that would necessitate being evaluated 
by a rehabilitation doctor 3 times per week. 
 
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. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the heat pad provided from May 5, 2022, to June 8, 2022. 
 
You asked the Plan to pay for the heat pad. The Plan denied your request. The Plan says that this item is 
excluded from coverage. 
 
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 argues that this item is excluded from coverage. However, the Plan has 
not provided documentation showing that item is not covered by Medicare or the Plan. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
heat pad provided from May 5, 2022, to June 8, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on March 13, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is 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 CPT code. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this code is included in the 
global surgery package of code 64450. Based on this information, we decided that Medicare rules for coverage 
of procedure code J3490 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code J3490 provided on March 13, 2023.
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. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for admission. 
 
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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service February 6, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4239 is considered bundled/excluded. 
 
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 A4239 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4239 is not separately payable/excluded. Based on this information, we decided that 
Medicare rules for coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4239 billed for date of service February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame table system (E0637) 
and miscellaneous durable medical equipment (E1399). 
 
You asked the Plan to pre-approve a combination sit to stand frame table system. You say that the medical 
records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says 
this item is a convenience item and not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a combination sit to stand frame table system (E0637) and 
miscellaneous durable medical equipment (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor V (F5) Leiden testing. 
 
You asked the Plan to pre-approve F5 testing. You say that you are trying to be proactive by getting this 
testing. The Plan denied your request. The Plan says this test is not covered for you. 
 
The Plan must follow Medicare rules. Medicare rules say that F5 genetic testing is not covered except for 
pregnant patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F5 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Factor V (F5) Leiden testing.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A0425 billed for date of service November 11, 2022.  
 
You asked the Plan to pay for code A0425. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that if a code has an MAI of 1, appropriate use of a 
modifier may be used to report the same code on separate lines of the claim.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 317 units of 
this code on one claim line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for code 
A0425 billed for date of service November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (code E0217) billed 
for dates of service October 7, 2022, to October 28, 2022. 
 
You asked the Plan to pay for code E0217. You say that the Plan initially denied this item for the incorrect 
reason. The Plan denied your request. The Plan says code E0217 is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that water circulating heat pads with pump billed 
with code E0217 are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0217 have not been met. Therefore, we decided that the Plan does not have to pay for the 
water circulating heat pad with pump (code E0217) billed for dates of service October 7, 2022, to October 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70486, 99204, and D7886 billed for July 13, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not 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. 
 In this case, the CPT Code Manual definition of code 70486 is computed tomography, maxillofacial area; 
without contrast material and 99204 is office or other outpatient visit for the evaluation and management of a 
new patient, which requires a medically appropriate history and/or examination and moderate level of medical 
decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the 
encounter. 
 
We find that CPT codes 70486 and 99204 are not supported in the medical record. Specifically, there are no 
submitted medical records for the billed date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met.  
 
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 D7886 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code D7886 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 70486, 99204, and D7886 billed 
for July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Papa Pals in-home support benefit. 
 
You asked the Plan to pre-approve in-home support benefit.. You say that you need additional in-home support 
service hours approved because you need help at home. The Plan denied your request. The Plan says you have 
exhausted your benefit limit for this service. 
 
 The Plan must follow Medicare rules. Medicare rules say that enrollees receive up to 60 hours per year of in-
home support services including light house help, companionship services, grocery shopping, technology 
lessons, and social transportation. 
 
We looked at the file and Medicare rules. The records show that you have used 60 hours between 
January 20, 2023, and July 2, 2023; therefore, no additional hours will be covered. Based on this information, 
we decided that Medicare rules for coverage of in-home support benefit. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Papa Pals in-home support benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc Allograft injection (0627T). 
 
You asked the Plan to pre-approve the injection procedure. You say that you are writing to demonstrate 
medical necessity and provide supporting documentation for coverage of the VIA Disc procedure. The Plan 
denied your request. The Plan says there are not enough studies on VIA Disc intradiscal therapy to show it is 
safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. More studies are needed to show VIA Disc intradiscal therapy is safe 
and effective. Based on this information, we decided that Medicare rules for coverage of the injection procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the VIA Disc 
Allograft injection (0627T).