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

 
We decided that the Plan does not have to pay for the urinary tract analysis panel provided on November 8, 
2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a 
urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large 
multiplex polymerase chain reaction (PCR) urinary tract infection panel tests. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the urinary tract analysis panel provided on November 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to the IRF is required as the enrollee's 
needs cannot safely be met at a lower level of care. The Plan denied your request. The Plan says the IRF 
services are not supported based on the records received.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiopulmonary exercise testing, including measurements of 
minute ventilation, CO2 production, O2 uptake, and electrocardiographic recordings rendered on February 6, 
2023. 
 
You asked the Plan to pay for the services. You say that the submitted documents should be reviewed. The Plan 
denied your request. The Plan says charges that are determined to be experimental and investigational are 
excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not benefit from any kind of stress test, including the requested cardiopulmonary 
test. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for cardiopulmonary exercise testing, including measurements of minute ventilation, CO2 
production, O2 uptake, and electrocardiographic recordings rendered on February 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services billed for dates of service August 17, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was transported due to a yeast 
infection. The Plan denied your request. The Plan says claims billed with the -GY modifier are statutorily 
excluded from coverage. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes A0425 and A0429 were billed with the -GY modifier. Services with the -GY modifier 
are not payable. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services billed 
for dates of service August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation (RFA) 
(64633, 64634). 
 
You asked the Plan to pre-approve thermal facet joint RFA. 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 thermal facet joint RFA is covered when specific 
criteria is 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 thermal facet joint RFA. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee has received only 
one diagnostic block at these levels. A repeat diagnostic block at these levels is required before performing 
RFA. Therefore, at this point, the request is deemed not medically reasonable and 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 thermal facet joint RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal facet joint radiofrequency ablation (RFA) (64633, 64634).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services to overcome mobility issues 
and address functional deficits. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator (E0466) provided on February 8, 2023. 
 
You asked the Plan to pay for the home ventilator. The Plan denied your request. The Plan says this request 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 pay for the home ventilator. Our reviewer says that 
the home ventilator is not medically reasonable and necessary for the enrollee. Our physician reviewer found it 
appears from the notes that, prior to obtaining the ventilator in July 2022, the enrollee had bilevel positive 
airway pressure (BiPAP) at home. The enrollee had stopped using the BiPAP prior to a hospitalization. Our 
reviewer found that there is also a history of being on chronic narcotics for air hunger. There is no record of a 
recent clinical visit, and no record of compliance with the current device. Our physician reviewer found that 
there are no pulmonary function tests to assess the severity of the COPD. There is no arterial blood gas (ABG) 
test done while stable to document chronic carbon dioxide retention. Our reviewer found that there is no 
documentation of failure of BiPAP as an outpatient. Our physician reviewer also found that Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pay for the home ventilator (E0466) provided on February 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are medically necessary, 
and you do not feel you are ready to go home. The Plan denied your request. The Plan says admission to the 
IRF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While You may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystourethroscopy with insertion of permanent 
adjustable transprostatic implant (Urolift procedure) (52442, 52441).  
 
You asked the Plan to pre-approve a Urolift procedure. You say that you have had to wear a catheter for six 
months while waiting for this surgery.  The Plan denied your request. The Plan says based on the clinical 
information provided, your prostate is not less than eighty (80) cubic centimeters.  
 
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 Urolift procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the American Urological Association (AUA) Guidelines recommend Urolift for 
patients with lower urinary tract symptoms (LUTS)/benigh prostatic hyperplasia (BPH) with prostate volume 30-80 cc and verified absence of an obstructive middle lobe. The records show that the prostate size is 90 cc 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 a Urolift procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cystourethroscopy with insertion of permanent adjustable transprostatic implant 
(Urolift procedure) (52442, 52441).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard-hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you are having issues with teeth grinding at 
night which is causing head pain, tooth cramps when drinking hot or cold drinks, and deteriorating of your 
teeth. You also say if this is not approved, you do not have the income to pay for it. The Plan denied your 
request. The Plan says the service is not a covered benefit under your dental plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard-hard appliance, full arch (D9944).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept ablation. 
 
You asked the Plan to pre-approve an outpatient procedure. You say that this procedure is medically necessary 
The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 an outpatient procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found enrollee has leg pain symptoms which are a contraindication to Intracept back pain 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Intracept ablation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 30, 2022, 
through April 28, 2022.  
 You asked the Plan to pay for the home health services. You say that this claim was billed correctly for 
medically necessary services.  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 January 29, 2022. The NOA was not received by the Plan until May 13, 
2022. As more than 30 days passed between the timely filing date and the 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 
provided from March 30, 2022, through April 28, 2022.
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 the enrollee clearly exceeds the criteria 
for a medically appropriate 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One injections.  
 You asked the Plan to pre-approve treatment with Synvisc-One. You say that this treatment is medically 
necessary.  The Plan denied your request. The Plan says there has been no trial of the preferred agent.  
 
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 treatment with Synvisc-One. Our 
reviewer says that the requested Synvisc-One treatment is not reasonable and necessary based on step therapy 
requirements.  Our physician reviewer found the enrollee is noted to have knee pain/osteoarthritis. A request 
has been made for Synvisc-One, a hyaluronic acid injection, to treat the knee pain/osteoarthritis. The health 
plan requires that Euflexxa be tried/used first. There is no evidence that the enrollee is allergic to or intolerant 
of Euflexxa. There is no evidence that the enrollee has tried and not responded to Euflexxa. There is no 
documentation as to why Euflexxa would not be expected to be safe and effective for the enrollee. As such, 
step therapy criteria are not 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 treatment with Synvisc-One have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Synvisc-One injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 25, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was not able to see a 
network provider on the denied date of service. The Plan denied your request. The Plan says services from non-
participating providers are not covered under an HMO plan unless preauthorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on May 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 You asked the Plan to pre-approve Retacrit. You say that the medication is recommended for the enrollee's 
treatment. The Plan denied your request. The Plan says that the step therapy requirements have not been met. 
 
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 Retacrit. Our reviewer says that 
Retacrit is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
required drugs Aranesp or Procrit. Also, there is no indication that the required drugs would likely be less 
effective or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve betamethasone dipropionate. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve betamethasone 
dipropionate.