Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA) (64635, 
64636). 
 
You asked the Plan to pre-approve 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 the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet certain criteria. 
 
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 facet joint RFA. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the RFA of the medial branches should 
last 6 months or more. There is a utilization limit of 2 sessions per rolling 12 months. This request exceeds that 
amount, and 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 facet joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint radiofrequency ablation (RFA) (64635, 64636).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); gastrointestinal pathogen, 12-25 targets (87507) provided January 24, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that based on the enrollee's specific clinical 
situation, the enrollee's physician ordered the test which is offered by you.  The Plan denied your request. The 
Plan says under Medicare guidelines, the service 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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the enrollee was not seriously ill, and the testing was not ordered by a 
clinician specialist in Infectious Diseases or Gastroenterology. The enrollee did not have signs or risks of 
severe disease that may warrant hospitalization, and symptoms were present for less than 7 days. The review 
has determined that the enrollee did not meet the coverage criteria for the obtained lab studies. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal 
pathogen, 12-25 targets (87507) provided January 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous-interlaminar fusion device lumbar 
(Minuteman device). 
 
You asked the Plan to pre-approve the Minuteman device. You say that refusing to allow coverage for this 
reasonable and necessary service to the member creates an unfair discrepancy in access to care. The Plan 
denied your request. The Plan says this device is considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Minuteman device. Our reviewer 
says that the requested Minuteman device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this device is considered experimental as more research is needed. Therefore, the 
reviewer found that the Minuteman device 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 the Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous-interlaminar fusion device lumbar (Minuteman device).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a decompression procedure (22869). 
 
You asked the Plan to pay for the decompression procedure. You say that this service was medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that that effective for services performed on or after 
January 09, 2014, CMS has determined that Percutaneous image-guided lumbar decompression for lumbar 
spinal stenosis is not reasonable and necessary. 
 
We looked at the file and Medicare rules. The procedure performed is non-covered under Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the decompression procedure have 
not been met. Therefore, we decided that the Plan does not have to pay for a decompression procedure (22869).
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 services are medically necessary for 
the enrollee to receive the care needed to regain their maximum function. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to 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 appears to be improving and should only require short-term additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for 
transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current 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: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140). We decided that the Plan does not 
have to pay for cone beam computed tomography capture of both jaws (D0367).  
 You asked the Plan to pay for a cone beam computed tomography capture of both jaws (D0367) and a limited 
oral evaluation (D0140) provided on April 7, 2023. You say that you had no idea that this provider was not in-
network. The Plan says that this procedure is not a covered benefit when rendered by a dentist who does not 
participate in this program. 
 
We decided that the Plan has to pay for a limited oral evaluation provided on April 7, 2023.  
 
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. The Plan rules say that this 
service is covered 100% both in and out-of-network. 
 
 We looked at the file and the Plan rules. The Plan rules say that this service is 100% covered both in and out-
of-network. Therefore, we decided that the Plan has to pay for a limited oral evaluation.  
 
We also decided that the Plan does not have to pay for a cone beam computed tomography capture of 
both jaws (D0367) provided on April 7, 2023. 
 
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 pay for a cone 
beam computed tomography capture of both jaws (D0367). 
 
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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you desperately need inpatient rehabilitation to 
regain your independence. You say that you had a nasty fall approximately one month ago and sustained a 
broken femur.  The Plan denied your request. The Plan says an IRF admission 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 acute IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 You asked the Plan to pre-approve Synvisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says 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 Synvisc. Our reviewer says that the 
requirements for coverage of Synvisc have not been met. Our physician reviewer found the Plan requires a trial 
of Euflexxa before they will approve Synvisc. In this case, the enrollee has not tried and failed the required 
drug. There is no documentation provided indicating that the required drug would likely be less effective or 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specific out-of-network brand of pneumatic 
compression device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there needs to be a medical reason for a specific brand to be requested. 
 
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. Medicare rules 
also say that contract suppliers are not required to furnish a specific brand name item or mode of delivery to a 
beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome.  
 
The provider at issue in this case is not a network provider with the Plan. 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 device. Our reviewer says that the requested device is not medically 
reasonable or necessary. Our physician reviewer found that the plan has appropriate in network services. The 
request is not urgent or emergent. 
 
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 device have not been met.  
 
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 the device. Therefore, we decided that the Plan does 
not have to pre-approve a specific out-of-network brand of pneumatic compression device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on April 
17, 2023. 
 
You asked the Plan to pay for the services. You say that you would like this claim to be reviewed and 
reprocessed as billed. The Plan denied your request. The Plan says the records do not support the services 
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. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records in this case 
do not document 2 out of 3 of an extensive number of diagnoses or management options, an extensive amount 
and complexity of data reviewed and high risk of complication. 
 
We looked at this coder'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 the emergency department visit (99285) provided on April 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dupixent pen (C9399). 
 
You asked the Plan to pre-approve the medication. You say that because of the enrollee's complicated case, 
they are an excellent candidate for Dupixent. You also say that you believe using Dupixent will be the most 
effective and beneficial way to prevent the enrollee's nasal polyps from growing back. 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 a Dupixent pen (C9399).  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto tablets. 
 
You asked the Plan to pre-approve the medication. 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 Xarelto tablets.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have taken 13 steps forward and 13 steps back. 
You say that you also do exercises with your spouse. The Plan denied your request. The Plan says an IRF 
admission 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of procedure code J9301 rendered on March 
21, 2022. 
 
You asked the Plan to pay for the services. You say that you are appealing the payment recoupment. The Plan 
denied your request. The Plan says excessive units were paid on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J9301 is "Injection, obinutuzumab, 10 mg." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation submitted did not include a medical record to verify medication, dosage and service billed. Therefore, this procedure code 
and the units cannot be verified. 
 
We looked at this coder'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 additional units of procedure code J9301 rendered on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurology appointment with an out-of-network (OON) 
tertiary care provider.  
 
You asked the Plan to pre-approve a neurology appointment with an OON tertiary care provider. You say that 
you were referred to the requested OON tertiary level of care facility because your doctor said that your 
medical state was beyond his expertise. You say that your referring provider said that you required a tertiary 
level of care and referred you to the requested OON provider who you are an established patient with.  The 
Plan denied your request. The Plan says the requested neurology services are available with in-network non-
tertiary level of care providers. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 neurology appointment with an OON 
tertiary care provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our 
physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to 
meet the enrollee's medical needs through referral to tertiary in-network neurology providers. There is nothing 
unique about the enrollee's condition that would make it medically necessary for him to see the requested OON 
provider.  
 
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 neurology appointment with an OON tertiary care provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a neurology appointment with an out-of-
network (OON) tertiary care provider.