Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injections. 
 
You asked the Plan to pre-approve Synvisc injections. You say that the denied authorization is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee did not meet the step 
therapy requirements. 
 
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 Synvisc injections. Our physician 
reviewer found that the Plan required a trial of Orthovisc or Supartz FX before they will approve Synvisc. Our 
physician reviewer found that based on the medical records provided there is no indication that the enrollee has 
tried and failed the required drugs. Our physician reviewer found that there is no indication that the Plans 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Synvisc injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted stomach procedure (43999), 
esphagogastroduodenoscopy (43239), and anesthesia (00731). 
 
You asked the Plan to pre-approve the endoscopic sleeve gastroplasty (ESG). You say that you are a liver 
transplant patient. You say that your provider feels you need this due to your weight issue. You say that you are 
trying to lose the weight but are struggling. You also say that your provider worries about heart issues down the 
road if you continue your weight gain. The Plan denied your request. The Plan says endoscopically performed 
bariatric procedures are not covered by Medicare as there is not sufficient clinical literature to suggest that 
these interventions are as good as or better than the standard. 
 
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 endoscopic sleeve gastroplasty (ESG). Our reviewer says that the requested ESG procedure is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested procedure is currently considered a potential 
treatment for obesity which has shown safety and efficacy in published studies, there are no randomized 
clinical trials (RCTs) comparing it to standard surgical treatments for obesity such as sleeve gastrectomy. There 
is insufficient data to support that ESG is as effective and durable treatment as current standard metabolic and 
bariatric surgery (MBS) procedures. The requested procedure remains investigational as a primary treatment 
for morbid obesity as most studies are small with limited patients and short follow-up duration without 3 to 5 
year long term follow-up data to support its efficacy and long-term durability. Therefore, the reviewer found 
that the requested ESG procedure 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 endoscopic sleeve gastroplasty (ESG) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the unlisted stomach procedure (43999), 
esphagogastroduodenoscopy (43239), and anesthesia (00731).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revision from sleeve gastrectomy to robotic-assisted 
laparoscopic gastric bypass with hiatal hernia repair and an associated inpatient admission.  
 You asked the Plan to pre-approve the bariatric surgery revision. You say that the procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested procedure is considered 
investigational given the lack of published evidence to support this as a safe, effective or durable treatment for 
post gastric bypass weight regain. 
 
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 bariatric surgery revision. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found conversion of sleeve gastrectomy to gastric bypass primarily for secondary 
weight loss has not been shown in prospective high-level studies to have durable outcomes. The reviewer found 
that this request for conversion appears to be primarily for weight loss. Conversion to gastric bypass from 
sleeve gastrectomy has been shown in published studies to be more effective for treatment of sleeve 
complications such as stricture or GERD, but significant and sustained weight loss is not always reported. The 
provided documentation indicates the enrollee is reported to have GERD, but esophagogastroduodenoscopy 
(EGD) showed no evidence of esophagitis, and the enrollee is not reported to be on any antacids. The 
documentation indicates that the enrollee has a sleeve with intact anatomy and some dilation without any overt 
correctable anatomic complication such as stricture for which conversion to gastric bypass can be considered 
therapeutic. Therefore, the reviewer found that the requested bariatric surgery 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 bariatric surgery revision have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a revision from sleeve gastrectomy to robotic-assisted laparoscopic gastric 
bypass with hiatal hernia repair and an associated inpatient admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is more than capable of participating in 
an IRF level of care and is highly motivated to return home. The Plan denied your request. The Plan says the 
request for an IRF admission does not meet the requirements for approval.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: 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 inpatient rehabilitation is both physically and 
medically necessary for the enrollee to return home at their maximum level of functioning with a decreased risk 
for readmission. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The clinical documentation shows that the enrollee requires ongoing skilled physical and 
occupational therapy however, it does not show that the enrollee would require an intensive rehabilitation 
regimen. 
 
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 ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
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 a ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is to be discharged from the hospital to 
the SNF and then to intensive outpatient care. The Plan denied your request. The Plan says a SNF admission is 
not medically necessary.  
 
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 you are requesting reconsideration for the denial of 
a continued SNF stay. The Plan denied your request. The Plan says you no longer require daily skilled therapy, 
and your needs can be safely met in a long-term care setting. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on March 12, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that due to the enrollee's 
conditions any other form of transport would be unsafe. The Plan denied your request. The Plan says the 
enrollee did not require the expertise of trained personnel or the equipment available only in an ambulance in 
order to effectuate a safe transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service and ground mileage. 
Our reviewer says that the ambulance transport services were not medically necessary.  
 Our physician reviewer found the transportation via ambulance from the hospital to the enrollees residence 
was not medically necessary. The enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport.  Transportation could have been 
provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering 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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on March 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the lab services and rehabilitation services 
provided from March 22, 2023, to March 24, 2023. 
 
You asked the Plan to waive the copayments for the lab services and rehabilitation services. You say that you 
should have been considered an inpatient. 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 copayment for in-network lab services. Your contract with the Plan also says that enrollees must pay a $30 
copayment for physical therapy services. Your contract with the Plan also says that enrollees must pay a $30 
copayment for occupational therapy services. 
 
You have been asked to pay a $10 copayment for each lab service. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. You have also been asked to pay a $30 copayment 
for the physical therapy services. You have also been asked to pay a $30 copayment for the occupational 
therapy services. These items/services fall within the outpatient rehabilitation 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 copayments for the lab services and rehabilitation services provided from 
March 22, 2023, to March 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798 and 87641 
billed for date of service November 7, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653, 87798 and 87641. You say that these 
services were reported correctly and are supported in the medical records. The Plan denied your request. The 
Plan says these services are not supported for separate reporting or payment. 
 
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 codes 87150, 87481, 87653, 87798 and 87641 are column II codes to 
column I codes 87500 and/or 87801; however, 87150, 87481, 87653, 87798 and 87641 were each billed with a 
modifier.  
 
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 procedure codes 87150, 87481, 87653, 87798 and 87641. 
Our reviewer says that these services are not supported for separate billing. Our reviewer found according to 
the medical records and NCCI edits, CPT codes 87150, 87481, 87653, 87798 and 87641 are not supported as 
separately identifiable procedures. They are included in the tests reported with 87801 and 87500. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87653, 87798 and 87641 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798 and 
87641 billed for date of service November 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory test codes 87481 and 87653 provided on October 
10, 2022. 
 
You asked the Plan to pay for lab test codes 87481 and 87653. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says these codes are included in the payment for code 87801 
so are 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. 
 
In this case, the CPT Code Manual definition of code 87481 is infection agent detection by nucleic acid; 
candida species, amplified probe technique. The CPT Code Manual definition of code 87653 is infection agent 
detection by nucleic acid; streptococcus, group B, amplified probe technique. 
 
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 lab test codes 87481 and 87653. Our reviewer says that these 
codes do not meet criteria for payment. Our reviewer found these codes were reported with procedure code 
87801. The laboratory report describes multiple organisms, amplified probe technique, in which these 
procedure codes would be inclusive. The report does not include documentation to support a separate service 
and these codes were not reported with a modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab test codes 87481 and 87653 have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory test codes 87481 and 87653 provided on October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150, 87481, 87653, and 87641 billed for 
date of service November 8, 2022. 
 
You asked the Plan to pay for procedure code 87150, 87481, 87653, and 87641. You say that this testing 
should be covered.  The Plan denied your request. The Plan says the codes at issue are considered to be 
bundled with the paid codes.  
 
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 codes 87481, 87653, and 87641 are column II codes in relation to column I 
codes 87150 and 87801. Code 87150 is a column II code in relation to column I code 87500. Though the 
column II codes were billed with modifier -XU, there is no evidence that these tests were distinct from the 
services described by the column I codes. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 87150, 87481, 87653, and 
87641 billed for date of service November 8, 2022.