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

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64483). 
 
You asked the Plan to pre-approve the injections. You say that it is medically necessary. The Plan denied your 
request. The Plan says it is not 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 injections. Our physician reviewer 
found the previous epidural steroid injection on May 5, 2023, provided 20-30 percent pain relief for a period of 
1-2 weeks. There is no documentation provided indicating that the provider will be using a different approach, 
level and/or medication. The review has determined that the requested epidural steroid injection does not meet 
the coverage criteria. The requested epidural steroid injection is not medically necessary or reasonable. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections (64483).
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 requires intensive inpatient rehabilitation 
with daily physician management, continuous specialized rehabilitation nursing, and intensive therapies to 
optimize mobility and strengthening while ensuring the restoration of functional status for a safe and 
sustainable discharge. The Plan denied your request. The Plan says the enrollee's condition does not meet 
Medicare guidelines for admission to an IRF.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports 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 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 the requested LTACH services are 
medically necessary. You would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says admission to an LTACH is 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 
services are 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 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 a cervical and vaginal cancer screening provided on  
July 12, 2023. 
 
You asked the Plan to pay for the cervical and vaginal cancer screening. You say that you understand this is 
usually a service covered every 2 years, however you are asking for this to be considered medically necessary 
as you are under the age of 65 and also a breast cancer survivor. The Plan denied your request. The Plan says 
you have exceeded the benefit limit and do not meet the benefit criteria for one Pap test every 12 months. 
 
The Plan contract says that the Plan covers a cervical and vaginal cancer screening. For all women: Pap tests 
and pelvic exams are covered once every 24 months. 
 
We looked at the file and the Plans rules. The file shows that you have exceeded the benefit limit and do not 
meet the benefit criteria for one Pap test every 12 months. Based on this information, we decided that the 
Plans rules for coverage of the cervical and vaginal cancer screening have not been met. Therefore, we 
decided that the Plan does not have to pay for a cervical and vaginal cancer screening provided on  
July 12, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis. 
 You asked the Plan to pre-approve Hymovis. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Hymovis. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the right knee. The documentation does not support that the enrollee has 
tried and failed Monovisc, Orthovisc, Synvisc, or Synvisc One. The documentation does not support that 
Monovisc, Orthovisc, Synvisc, or Synvisc One would likely be less effective and/or likely have adverse effects 
for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular breast imaging provided on February 23, 2023. 
 
You asked the Plan to pay for molecular breast imaging. You say that molecular breast imaging was medically 
necessary. The Plan denied your request. The Plan says the requested molecular breast imaging is not the 
standard of care and was 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 pay for molecular breast imaging. Our reviewer says 
that the requested molecular breast imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found that the molecular based imaging was not medically necessary in an 
asymptomatic patient with heterogeneously dense tissue, negative physical exam, negative mammogram and 
no genetic predisposition to breast cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of molecular breast imaging have not been met. Therefore, we decided that the 
Plan does not have to pay for molecular breast imaging provided on February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventive medicine counseling provided on June 26, 2023. 
 
You asked the Plan to pay for preventive medicine counseling. You say that the services were medically 
necessary 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 preventive medicine 
counseling provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on May 1, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or cleared indication for use in this enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Tempus xF testing (81455) provided on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve this 
dental work. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your quarterly annual coverage of $1,000 has been exhausted. Any additional charges over $1,000 is the 
enrollees responsibility. Therefore, we decided that the Plan does not have to pre-approve dental services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dressing changes and/or debridement 
procedures provided on March 1, 2023, to March 22, 2023. 
 
You asked the Plan to waive the copayment for the dressing changes and/or debridement procedures. You say 
that you were unaware that you were having surgery. 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 $350 
copayment for surgery services.  
 
You have been asked to pay $170.58, which is less than the standard copayment for each dressing change 
and/or debridement procedure provided on March 1, 2023, March 8, 2023, and March 15, 2023. You have also 
been asked to pay a $350 copayment for the dressing change and/or debridement procedure provided on March 
22, 2023. These items/services fall within the outpatient hospital services 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 the dressing changes and/or debridement procedures provided on 
March 1, 2023, to March 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
March 6, 2023, to March 9, 2023. 
 
You asked the Plan to pay for procedure codes 20936 and 20930. You say that this claim was denied in error, 
and you have supplied medical records to support payment. The Plan denied your request. The Plan says 
procedure codes 20936 and 20930 are 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 codes 20936 and 20930 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20936 and 20930 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20936 and 20930 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
March 6, 2023, to March 9, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve the 10 physical therapy visits. You say that you are appealing the medical 
necessity denial for outpatient physical therapy visits because of mixed incontinence. The Plan denied your 
request. The Plan says the requested physical therapy visits have been denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health 
plan. The records do not demonstrate that the unique skills of a professional therapist are required to safely and 
effectively provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 10 physical therapy visits.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says the IRF services are not medically necessary.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 17, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81456 is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 29, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81456 is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service March 21, 
2023. 
 
You asked the Plan to pay for procedure code 99053. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service March 21, 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. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records show the enrollee is ill with a significant decline with 
baseline function and have have been medically stabilized. The Plan says that the 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 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.