Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 5 home health physical therapy (PT) visits (two were approved).

You asked the Plan to pre-approve the additional home health services. You say that you feel that more visits are 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 the additional home health services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the member is a 79-year-old female with a medical history including hypertension, chronic kidney disease and previous infection with COVID-19 with resulting weakness who has been receiving home health physical therapy since at least November 2022. The documentation indicates the member's function has improved and she can ambulate household distances using a walker and contact guard assistance. The health plan has authorized an additional 2 visits to reenforce a home exercise program.

The documentation does not support that the member requires additional skilled rehab services to provide treatment that is medically necessary. The member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 5 home health physical therapy (PT) visits (two were approved).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral stab phlebectomy (37765). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the medical records do not 
support that the enrollee meets the 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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found for tributary treatment such as stab phlebectomy to be considered medically 
necessary per coverage criteria, there needs to be persistent significant symptoms following successful 
treatment of truncal (saphenous) reflux with these symptoms existing more than 6 weeks after the reflux was 
treated and despite conservative efforts.  Additionally, the veins to be treated need to be at least 4 mm in 
diameter (this size related criterion is met).  As the enrollee has not yet undergone saphenous vein reflux 
treatment, all criteria have not been met.  The health plan does not provide for simultaneous saphenous reflux 
treatment and tributary treatment.  A rationale for this is that many patients experience satisfactory relief with 
the truncal intervention alone. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the bilateral stab phlebectomy (37765).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for office visits provided on August 11, 2022, 
to February 1, 2023. 
 
You asked the Plan to waive the cost sharing for office visits. You say that you are disputing the share cost. 
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 40% coinsurance for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay 40% coinsurance for office visits. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 cost sharing for office visits provided on August 11, 2022, to February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant control. 
 
You asked the Plan to pre-approve attendant control. 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 if an attendant control (E2331) is provided in addition 
to a beneficiary-operated drive control system, it will be denied as non-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 attendant control. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has capacity based on 
info provided to manage a power wheelchair. Attendant control is not medically necessary per the coverage 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of attendant control have not been met. Therefore, we decided that the Plan does 
not have to pre-approve attendant control.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT).

You asked the Plan to pre-approve SPECT. You say that this test is medically necessary. The Plan denied your request. The Plan says the notes sent by your doctor show that you are able to walk daily for 30 minutes and do not have any symptoms

The Plan follows Medicare rules. Medicare rules say that SPECT imaging is covered when it is medically reasonable and necessary.

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 SPECT. Our reviewer says that this imaging is not medically necessary. Our physician reviewer found that you have no cardiac symptoms. There is no documentation that the electrocardiogram (ECG) shows an uninterpretable pattern or that you are unable to exercise. There is no evidence provided that would support the need for radionuclide stress testing at this time. In summary, there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in your clinical 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 SPECT have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Perjeta infusions. 
 
You asked the Plan to pre-approve Perjeta infusions. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Perjeta infusions. Our reviewer says 
that the services are medically necessary. Our physician reviewer found there is compelling data to suggest 
potential for a meaningful benefit from the initiation of treatment with an aromatase inhibitor plus HER2-
directed therapy with pertuzumab and trastuzumab with an acceptable safety profile. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Perjeta infusions have been met. Therefore, we decided that the Plan has to pre-
approve Perjeta infusions.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on 
December 15, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you are disputing the 
share cost. 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 $20 per 
day for days 1-20 for Skilled nursing facility (SNF) care. This skilled nursing facility service lasted 11 days, 
resulting in a copayment amount of $220 ($20 per day for 11 days = $220). 
 
You have been asked to pay $20 per day for days 1-20 for skilled nursing facility. This item/service falls within 
the Skilled nursing facility (SNF) care 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 copayment for 
skilled nursing facility provided on December 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that services from an out-of-network 
provider are necessary because you are often unable to travel and the services you need are not available from 
an in-network provider. The Plan denied your request. The Plan says you must receive your care from a 
network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug, single administration 
(D9610). 
 
You asked the Plan to pre-approve the therapeutic parenteral drug. The Plan denied your request. The Plan says 
this code is not listed in the table of covered services. 
 
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 
therapeutic parenteral drug, single administration (D9610).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in 
the home health or hospice setting, each 15 minutes (G0151 x 3). 
 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 
documentation doesnt support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  The 
requested home health services are 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 services performed by a qualified physical therapist in the home health or hospice 
setting, each 15 minutes (G0151 x 3).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (99306). 
 
You asked the Plan to pre-approve the service. You say that this service is medically necessary as the enrollee 
previously had an abnormal echocardiogram. The Plan denied your request. The Plan says this service is not 
medically necessary as the enrollee has no cardiac symptoms and is medically stable from a cardiac standpoint. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no supportive evidence for the medical necessity of TTE in this this enrollee's clinical 
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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transthoracic echocardiography (TTE) (99306).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the PBRT. You say that the PBRT is medically necessary. The Plan denied 
your request. The Plan says that this is experimental/investigational for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 PBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found with the case records showing clinically meaningful reductions in oral cavity and parotid 
exposures (conceding that these comparisons can artificially be made to look bad for the non-proton plan) 
proton therapy can be considered necessary and would meet American Society for Radiation Oncology 
(ASTRO) and National Comprehensive Cancer Network (NCCN) criteria and would be within accepted 
standards 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 the PBRT have been met. Therefore, we decided that the Plan has to pre-
approve the proton beam radiation therapy (PBRT).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you qualify for the SSBCI 
benefits but were denied. The Plan denied your request. The Plan says the criteria for eligibility have not been 
met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unused over-the-counter (OTC) allowance from the 
first quarter. 
 
You asked the Plan to pre-approve the unused OTC allowance from the first quarter. You say that you were not 
aware this allowance was something you still had, and you would like your amount from the first quarter to be 
put on your account. The Plan denied your request. The Plan says your OTC benefit allowance per quarter 
cannot be carried over to another quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items, however, your 
Plan offers a quarterly supplemental allowance for certain OTC drugs. The contract clearly states that quarterly 
allowances cannot be carried over to another quarter. Therefore, we decided that the Plan does not have to pre-
approve the unused over-the-counter (OTC) allowance from the first quarter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says this surgery can be performed as an ambulatory procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 acute inpatient hospital care. Our reviewer 
says that the enrollee does not meet criteria for the requested inpatient level of care. Our physician reviewer 
found the documentation does not reveal any unstable conditions or special circumstances to expect that the 
enrollee will require hospital care that would likely span at least 2 midnights. This procedure is typically 
ambulatory. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital level of care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code 22830. 
 
You asked the Plan to pre-approve procedure code 22830. You say that the services are necessary. The Plan 
denied your request. The Plan says payment for code 22830 is bundled into payment for code 22207 and code 
22800. 
 
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 22830 
is a column II code to column I code 22207 and code 22830 is a column II code to column I code 22800. 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 pre-approve 
procedure code 22830.