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 meets the criteria for an 
LTACH level of care. The Plan denied your request. The Plan says the enrollee's medical needs are being met 
in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. 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 health plan. Given there are offered alternatives, LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (85060) provided July 20, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. No payment is 
recognized for code 85060 furnished to hospital outpatients or non-hospital patients. The physician 
interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test. Place 
of service 22-Outpatient was listed on the claim. Per Centers for Medicare & Medicaid Services (CMS), If a 
CPT/HCPCS code with a PC/TC indicator of 8 for the claim line date of service is billed in a Place of Service (POS) that is NOT 21 (hospital inpatient), the logic within this edit will apply a recommendation to deny the 
claim line per CMS Medicare Physician Fee Schedule. Therefore, we decided that the Plan does not have to 
pay for the laboratory service (85060) provided July 20, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TMS. 
 
You asked the Plan to pre-approve TMS. You say that TMS is medically necessary. The Plan denied your 
request. The Plan says outpatient therapy should be tried. 
 
The Plan follows Medicare rules. Medicare rules say that TMS is covered when the criterial listed in the 
Medicare rules section of this decision are met. 
 
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 TMS. Our reviewer says that the 
requested TMS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case do not document a trial of an evidence-based psychotherapy known 
to be effective in the treatment of major depressive disorder of an adequate frequency and duration without significant improvement in depressive symptoms as documented by standardized rating scales that reliably 
measure depressive symptoms and as required by the Medicare LCD L34641. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TMS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 99348 provided on October 06, 2023, to October 20, 2023. 
 
You asked the Plan to pay for 99348. You say that this provider is the only wound care specialist who works 
for the enrollees assisted living home. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 99348 provided on October 06, 2023, to October 20, 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 The Plan says services may be provided at a lower 
level of care. The Plan denied your request. The Plan says the records do not show the enrollee's rehabilitation 
needs are complex. The Plan says services needed can be provided safely in other settings, at home with home 
health services or home with outpatient therapy.  
 
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 medical 
records support a need for physical 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. It 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 these services Our reviewer says that 
you do not meet criteria for coverage of the requested services. Our physician reviewer found that in this case, 
the record indicates that you have a lumbar radiculopathy. The records provided do not document the presence 
of a subluxation either by physical examination or radiographic images.  
  
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules,  
of the requested services. The elements of the coverage criteria are not satisfied. The requested services are not 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on July 19, 2023. 
 
You asked the Plan to pay for the surgery services. You say that you say that the service was 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 the surgery services provided on July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0480) provided September 20, 2023. 
 You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
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 G0480 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed. 
 
The submitted medical records do not contain sufficient details to support the billed code. The Plan states the 
submitted order does not indicate a clear intent to order this test and the submitted order does not indicate the 
specific tests included in the custom panel being requested; therefore, the billed code cannot be verified. Based 
on this information, we decided that Medicare rules for coverage of the drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing (G0480) provided September 20, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve romosozumab. 
 You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the enrollee has not tried and failed preferred 
medications. 
 
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 the medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the Plan requires a trial of alendronate, zoledronic acid, and ibandronate before they will approve the 
requested drug. In this case, the patient has not tried and failed the required drugs. 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. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve romosozumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodontal maintenance D4910 provided 
on August 16, 2023. 
 
You asked the Plan to waive the coinsurance for periodontal maintenance D4910. You say that this should be 
covered. 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 50% 
coinsurance for periodontal maintenance. 
 
You have been asked to pay 50% coinsurance for periodontal maintenance D4910. This item/service falls 
within the periodontal maintenance 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 coinsurance for 
periodontal maintenance D4910 provided on August 16, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rixuan. 
 You asked the Plan to pre-approve Rixuan. You say that Rixuan is medically necessary. The Plan denied your 
request. The Plan says a trial of Ruxience or Truxima is required before alternatives can be considered. 
 
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 Rixuan. Our reviewer says that Rixuan 
is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs 
or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rixuan have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Rixuan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TissueCypher Barret's Esophagus testing (0108U). 
 
You asked the Plan to pre-approve TissueCypher Barret's Esophagus testing. You say that you need this test. 
The Plan denied your request. The Plan says this testing is not medically necessary as it is not approved or 
covered by Medicare. 
 
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 TissueCypher Barret's Esophagus 
testing. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have undergone foregut evaluation and were found to 
have gastroesophageal reflux disease, hiatal hernia and Barrett's esophagus indefinite for dysplasia. The review 
has determined that the requested test does not have enough reviewed data on the safety and effectiveness in the literature to show that the test meets the standards of medical practice. The review has determined that the 
items/services at issue in this case are not 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 TissueCypher Barret's Esophagus testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve TissueCypher Barret's Esophagus testing (0108U).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. 
 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a CardioMEMS device (33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, 
E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no medical need to control the power options through the joystick. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the separate request for the positioning wedge (K0108) is not medically necessary, as it is 
all inclusive. Additionally, for the other codes, the enrollee's upper extremity strength and functional ability 
support that this patient can control any power options through their own switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (K0108, E2311, E2313, E2377).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy and esophagogastroduodenoscopy 
(43235, 45380). 
 
You asked the Plan to pre-approve a colonoscopy and esophagogastroduodenoscopy. 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 follows Medicare rules. Medicare rules say that a colonoscopy is covered when specific criteria are 
met. 
 
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 colonoscopy and 
esophagogastroduodenoscopy. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found based on the documentation, there is not a clear indication for a colonoscopy and therefore does 
not meet the LCD. 
 
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 colonoscopy and esophagogastroduodenoscopy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a colonoscopy and esophagogastroduodenoscopy 
(43235, 45380).
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 has a new (acute) medical. surgical, 
neurological condition that has resulted in a significant decrease in functional ability and cannot adequately 
recover in a less intensive setting. The Plan denied your request. The Plan says the enrollee's condition does not 
meet all the requirements for inpatient rehabilitation admission. The Plan says services may be provided at 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. The medical 
records support a need for physical 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. It 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.