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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 
 
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 
enrollee does not meet criteria for SNF admission. Our physician reviewer found the enrollee may require 
skilled nursing care in terms of the complexity of her multiple pressure wounds. However, she was recently 
discharged from a skilled nursing facility on October 27, 2023, and continues to require maximum assistance to 
be dependent with bed mobility, transfers and performing most of her daily activities. She remains non-
ambulatory. She will continue to require assistance with daily activities and mobility, but she does not require 
skilled therapy in the skilled nursing facility 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a T8 kyphoplasty (22513). 
 
You asked the Plan to pre-approve a T8 kyphoplasty. You say that the fracture is osteoporotic in nature as it is 
not the result of a fall or trauma. You say that the enrollee was unable to get a DEXA scan as it was too soon to 
repeat the test. You also say that the enrollee has tried extensive conservative treatment without adequate relief. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty may be considered medically reasonable 
and necessary when a vertebral compression fracture is present for up to 12 weeks and documented by 
advanced imaging. 
 
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 T8 kyphoplasty. Our reviewer says 
that the requested T8 kyphoplasty is not medically necessary. Our physician reviewer found the provided 
records indicate that the enrollee's symptoms began in late June 2023. The reviewer found that this procedure 
was not requested until more than 12 weeks had passed since the onset of the pain. Therefore, the reviewer 
found that the requested T8 kyphoplasty 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 a T8 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a T8 kyphoplasty (22513).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Synvisc or Synvisc-One, for 
intra-articular injection (J7325). 
 You asked the Plan to pre-approve the medication. You say that the enrollee has had viscosupplementation 
injections in the past which seemed to have long lasting relief.  The Plan denied your request. The Plan says 
this request does not meet the Plan's step therapy criteria for the requested viscosupplement device.  
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found step therapy, as outlined by the plan, requires that one of the preferred viscosupplemental 
treatments (Orthovisc or Supartz FX) be trialed first. The documentation does not outline contraindications or 
reasons these medications were not considered or that the Plan's additional required drugs would likely be less 
effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, 
Synvisc/Synvisc-One 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 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan needs to pay for this. The 
Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service July 6, 223. Therefore, we decided that the Plan does not have to pay any amount over $2,000 for dental services provided on July 6, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 10, 2023, to 
April 8, 2023. 
 
You asked the Plan to pay for the home health services. You say that the Notice of Admission was submitted 
for these services. The Plan denied your request. The Plan says you did not bill this claim with one of the 
required Q codes.  
The Plan must follow Medicare rules. Medicare rules say that HHAs must report where home health services 
were provided using one of the following codes: Q5001, Q5002, or Q5009. 
 
In this case, you did not bill the location of the services with one of these required Q codes. We looked at the 
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home 
health services have not been met. Therefore, we decided that the Plan does not have to pay for home health 
services provided from March 10, 2023, to April 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral radiographic image (D0250), and panoramic 
imaging (D0330) provided on June 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe this is fraud. The Plan denied your 
request. The Plan says these services have been correctly denied. 
 
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 benefit for the requested item or service was exhausted on date of service June 23, 2023. You are 
not being charges for a limited oral evaluation (D0140). Therefore, we decided that the Plan does not have to 
pay for a 2D oral radiographic image (D0250), and panoramic imaging (D0330) provided on June 23, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drugs.  
 
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 Gel-One. Our physician reviewer found 
that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The Plan requires a trial 
of Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One before they will approve the requested drug. 
The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the plan's preferred step one alternative. 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferumoxytol. 
 You asked the Plan to pre-approve Ferumoxytol. You say that Ferumoxytol is medically necessary. The Plan 
denied your request. The Plan says a trial of oral iron supplements is required before Ferumoxytol 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 Ferumoxytol. Our reviewer says that 
Ferumoxytol is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they are 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 Ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ferumoxytol.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 3, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided from June 8, 2023, to June 22, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that you were not aware that the enrollee's Plan 
required prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visits provided from June 8, 2023, to 
June 22, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 21, 2022. 
 
You asked the Plan to pay for the physician service. You say that this should be reprocessed and paid. The Plan 
denied your request. The Plan says this claim was not filed within 12 months from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician service was not filed until May 5, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on April 17, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that the paring of the callus was medically 
necessary as it was impacting the members mobility and causing her pain. The Plan denied your request. The 
Plan says routine foot care is statutorily excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry 
services provided on April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says there was insufficient information provided to review this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Specifically, no medical records or literature was provided to support the service at issue. Only lab results were 
submitted. No office or clinical notes were provided to support medical necessity of this service. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion services (96366, J1745, 96365, 96375) provided 
on April 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the infusion services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the infusion services (96366, J1745, 96365, 
96375) provided on April 25, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the semi-electric hospital bed (E0260) purchased July 17, 
2023 
 
You asked the Plan to pay for the hospital bed. You say that you were told you can purchase the bed submit the 
bill for reimbursement of the cost. The Plan denied your request. The Plan says the item was purchased from a 
supplier that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the semi-electric hospital bed (E0260) 
purchased July 17, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170-26 billed for date of service June 2, 
2023. 
 You asked the Plan to pay for procedure code 72170-26. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 72170-26 is bundled into payment for 
code 73521-26. 
 
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 
72170-26 is a column II code to column I code 73521-26. This claim has not been billed with an appropriate 
modifier to bypass the edit. 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 72170-26 billed for date of service 
June 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health (HH) skilled nursing (SN) visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary.  
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
noted to be medically stable. They do not require wound care, catheterization, G-tube feeding, or 
administration of IV or complex medications. The enrollee has been educated regarding their medications and 
they have not recently been hospitalized. They have been educated with regards to home and mobility safety. 
They are independent with mobility. Therefore, the continued home health skilled nursing care is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health (HH) skilled nursing (SN) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFCI repeat expansion testing. 
 
You asked the Plan to pre-approve RFCI repeat expansion testing. You say that this testing is needed to 
determine the underlying etiology of the enrollee's condition and guide management. The Plan denied your 
request. The Plan says the records do not show that this testing would directly impact the enrollee's testing. 
 
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 RFCI repeat expansion testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided records do not document prominent symptoms of ataxia and the 
enrollee's gait is reported as normal on the neurological examination on August 30, 2023. Records also report 
no chronic cough which is often seen in CANVAS. A follow-up visit on October 16, 2023 stated, "Even if a causative mutation is identified, it cannot be guaranteed that this should change the enrollee's current medical 
management." Overall, the records do not support that this testing is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFCI repeat expansion testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve RFCI repeat expansion testing.