Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
enrollee does not meet the guidelines for care in an LTACH. 
 
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 has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied.  The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air transportation services identified with codes A0431 
and A0436 for date of service September 16, 2022. 
 
You asked the Plan to pay for the air transportation services identified with codes A0431 and A0436. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
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 codes A0431 and A0436 are not supported in the medical record. Specifically, these services 
were billed with modifier GZ. Claim lines with GZ modifier are automatically denied as non-covered services. 
Based on this information, we decided that Medicare rules for coverage of the air transportation services 
identified with codes A0431 and A0436 have not been met. Therefore, we decided that the Plan does not have 
to pay for the air transportation services identified with codes A0431 and A0436 for date of service September 
16, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced foot and ankle (L5984, L5987) for a lower-limb 
prosthesis. 
 
You asked the Plan to pre-approve an advanced foot and ankle. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the requested items are not 
medically necessary because the enrollee is not a K3 ambulator. 
 
The Plan follows Medicare rules. The rules say that a lower limb prosthesis is covered when the beneficiary: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an advanced foot and ankle. Our 
reviewer says that the requested items are medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee's K3 status is well documented in the medical record. The record explicitly 
documents in detail the enrollee's potential to return to unlimited community ambulation, which the enrollee 
was noted to be able to do before admission. Regarding the Plans assertion that the enrollee requires a 
wheelchair and walker, there is no comment on the enrollee needing those devices outside of the inpatient 
setting and while the enrollee is waiting on a new prosthesis. Moreover, occasional use of assistive devices 
would not, on its own, disqualify an enrollee from K3 status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an advanced foot and ankle have been met. Therefore, we decided that the Plan 
has to pre-approve an advanced foot and ankle (L5984, L5987) for a lower-limb prosthesis.  
 
  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT) 
(77373x3). 
 
You asked the Plan to pre-approve SBRT. You say that the procedure is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the request does not meet the Medicare or health plan coverage 
criteria. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SBRT, delivering high fractional doses in 3-5 fractions is an established approach for the 
treatment of discrete lesions from cancer. For metastatic disease, SBRT is generally indicated for enrollees with 
oligometastatic disease of for those undergoing palliation after prior radiation to the same site. Comparing 
image-guided radiosurgery or SBRT with external beam radiotherapy in enrollees with localized spine 
metastases, showed no benefit of SBRT over conventional radiotherapy for the treatment of spine metastases 
with respect to pain control at three months or quality of life. From this study routine use of SBRT for spine 
metastases is not considered standard. Based on the ASTRO model policy, routine use of SBRT for palliation 
of spine metastases in the setting of more widespread disease is not in accordance with accepted standards of 
medical practice. The decision is therefore unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRT) (77373x3).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on December 20, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test provided on December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower limb prosthesiss (L5629, L5670, L5647, L5968, 
L5301, L5637, L5910, L5940, L5981, L8400x6, L8420x6, L8440x6, L8470x6, L5620x2). 
 
You asked the Plan to pre-approve lower limb prosthesiss. You say that you disagree with the denial. The Plan 
denied your request. The Plan says there is no documentation by the ordering provider that meets the criteria 
for an accepted SWO. 
 
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. The records show that a SWO must be communicated to the supplier 
before a claim is submitted. Based on this information, we decided that Medicare rules for coverage of lower 
limb prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve lower 
limb prosthesiss (L5629, L5670, L5647, L5968, L5301, L5637, L5910, L5940, L5981, L8400x6, L8420x6, 
L8440x6, L8470x6, L5620x2).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81455) provided on July 12, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that this claim is denied. 
 
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. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to pay for laboratory services (81455) provided on 
July 12, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Visco-3 (J7321). 
 You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has tried or cannot use Orthovisc or Supartz FX. (step 
therapy requirement) 
 
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 physician reviewer 
found the provider has requested viscosupplementation with Visco-3 to treat the pain due to osteoarthritis of 
the knee. The enrollee has not trialed one viscosupplemental treatment such as Orthovisc or Supartz FX. Step 
therapy, as outlined by the Plan, requires that one of these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered. Without the support of the documentation, 
Visco-3 is not approved as step 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Visco-3 (J7321).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are requesting reconsideration of the 
denied authorization for therapy services. The Plan denied your request. The Plan says that the additional 
therapy services are not medically necessary. 
 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 therapy services. 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 that the enrollee has previously been treated with outpatient therapies 
and should be independent with a home exercise program. There is no documentation of a recent injury or 
decline in function. The additional therapy services are not an appropriate duration and frequency for treatment 
of the enrollees medical 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
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 services are necessary for the enrollee to 
continue receiving speech, physical and occupational therapy. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
The Plan denied your request. The Plan says ongoing skilled care can be provided in an alternative 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 that the enrollee does not qualify for SNF coverage. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (the Life2000) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the ventilator is not medically necessary. 
 
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 the ventilator. Our physician reviewer 
found the case file does not contain documentation of trial and failure of bilevel positive airway pressure (BiPAP) with backup rate and average volume-assured pressure support (AVAPS). The documentation is 
insufficient to support that a home ventilator (E0466) is medically reasonable and necessary in this case. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator (the Life2000) (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these services are included in the dialysis rate. The Plan 
denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 31, 2022, to 
November 29, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 31, 2022. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and an NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered from October 
31, 2022, to November 29, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the percutaneous vertebral augmentation provided from January 16, 
2023, to January 23, 2023. 
 
You asked the Plan to pay for the procedure. The Plan denied your request. The Plan says that the coverage 
criteria are not met. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the procedure by a contract provider. The file does not show that the Plan provided notice 
that the procedure would not be covered. Under Medicare rules, this means the procedure is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the percutaneous vertebral 
augmentation provided from January 16, 2023, to January 23, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad (E1028). 
 
You asked the Plan to pre-approve a fluid circulating cold pad. You say that this device is necessary to promote 
healing after surgery. The Plan denied your request. The Plan says that this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad (E0218) is not 
covered. 
 
Although this item may be appropriate, it is not covered by Medicare or the Plan Therefore, we decided that the 
Plan does not have to pre-approve a fluid circulating cold pad (E1028).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 15, 2022.