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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the patient does meet the Centers for 
Medicare & Medicaid Services (CMS) LTACH admission criteria. You also say that the patient's ongoing 
medical care warrants an LTACH level of care. The Plan denied your request. The Plan says the criteria for 
admission to the LTACH have not been met. 
 
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 patient is receiving appropriate care in current acute care setting as provided by 
Health Plan. Our reviewer also found that the documentation does not support that LTACH services are 
medically appropriate at this time. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full criteria for an IRF stay. You 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
IRF services requested do not meet the requirements for approval.  
 
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 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. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches (64624) with moderate sedation (99152).  
 
You asked the Plan to pre-approve destruction by neurolytic agent with moderate sedation. You say that you 
are requesting reconsideration with medical records to support the appeal. The Plan denied your request. The 
Plan says the requested services do not meet the requirements for approval. 
 
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 destruction by neurolytic agent with 
moderate sedation. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the requested service is considered an experimental/ 
investigational therapy and is the subject of ongoing clinical trials. Therefore, 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 destruction by neurolytic agent with moderate sedation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular 
nerve branches (64624) with moderate sedation (99152).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that you are appealing the denial with 
supporting medical records. The Plan denied your request. The Plan says this device 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 pre-approve a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of the CardioMEMS device in patient management. As a result, at 
this time the CardioMEMS system would not be considered medically appropriate and necessary in the 
enrollees 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the implantation of a CardioMEMS device.
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. The Plan denied your request. The Plan says an SNF admission is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pacemaker evaluation provided on February 2, 2023, by an 
OON provider.  
 
You asked the Plan to pay for a pacemaker evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested 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 a pacemaker evaluation provided on February 2, 
2023, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from 
December 8, 2021, to January 6, 2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that home health agencies (HHAs) must submit HH 
PPS claims with the 4th digit of 9. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim at issue has not been submitted 
with the appropriate Type of Bill code. Therefore, we decided that the Plan does not have to pay for home 
health services billed for dates of service from December 8, 2021, to January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99221 billed for dates of service September 29, 2022, to 
September 30, 2022. 
 
You asked the Plan to pay for code 99221. You say that you initially billed this service with code 99222.  
However, you submitted a corrected claim, down-coding this service to 99221. You believe that code 99221 is 
supported by the medical record. The Plan denied your request. The Plan says code 99221 is not supported by 
the medical record.  
 
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 99221 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. 
 
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 code 99221. Our reviewer says that code 99221 is not 
supported by the medical record. Our reviewer found there is no review of systems at all in this documentation. 
The provided records from September 29, 2022, in this case do not document an extended examination of the 
affected body area. The only examination findings are vital signs.  The provided records in this case document 
2 out of 3 of a minimal number of diagnoses or management options, a minimal amount and complexity of data 
reviewed and minimal or low 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 code 99221 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99221 billed for dates of service September 29, 2022, to September 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover the requested study for 
screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a 
screening service. When performed in association with CT angiography, there is neither separate nor additional 
included reimbursement for the calcium scoring.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT scan of the heart have not been met. Therefore, we decided that the Plan does not have to pre-
approve a CT scan of the heart.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 16, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting refund. The Plan denied your 
request. The Plan says you do not have supplemental benefit. 
 
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 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 an office visit provided on March 16, 2023, by an 
out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis. The documentation does not support that the enrollee has a history of 
osteoporotic fracture or has tried or cannot use zoledronic acid. The documentation does not support that 
zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 18, 2023, billed with 
procedure codes 96365-59 and 96366-59 (2 units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 96365-59 and 96366-59 is intravenous infusion, for 
therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, and intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in 
addition to code for primary procedure). 
 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found the billed codes are not supported as 
there is a more specific code to report for the service documented. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 18, 2023, billed with procedure codes 
96365-59 and 96366-59 (2 units).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kenevo knee (L5828 + L5845+ L5848 + L5856), 
above knee disarticulation (L5920), and ultralight material (L5950). 
 
You asked the Plan to pre-approve a Kenevo knee, above knee disarticulation, and ultralight material. You say 
that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Kenevo knee, above knee 
disarticulation, and ultralight material. Our reviewer says that the items are not medically necessary. Our 
physician reviewer found the requested exoskeletal prosthesis additional codes are not compatible with the 
patient's approved endoskeleton system knee. Additionally, the documentation does not support that the 
patient's activities require a K3 knee. The documentation does not support that the patient requires a heavier 
microprocessor knee over a mechanical knee.  
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 Kenevo knee, above knee disarticulation, and ultralight material have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Kenevo knee (L5828 + L5845+ L5848 
+ L5856), above knee disarticulation (L5920), and ultralight material (L5950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs (K0739, E0973, E2619, 
E2624, K0040, K0077, K0108). 
 You asked the Plan to pre-approve wheelchair repairs. You say that the enrollee was approved for a new 
wheelchair, but he refused the chair and cancelled the order. The enrollee would like his current wheelchair 
repaired instead. The Plan denied your request. The Plan says the cost for repairs exceeds the cost of a 
replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that during the reasonable useful lifetime,  
Medicare does cover repair up to the cost of replacement.  
 
We looked at the file and Medicare rules. The records show that the enrollee has had seven prior repairs on the 
current wheelchair and the cost for repairs exceeds the cost of replacement, therefore, the requested repairs do 
not meet the plans coverage criteria. Based on this information, we decided that Medicare rules for coverage 
of wheelchair repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve 
power wheelchair repairs (K0739, E0973, E2619, E2624, K0040, K0077, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device (K1018). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that a Cala Trio device is a necessity for your 
care. The Plan denied your request. The Plan says a Cala Trio device is 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 a Cala Trio device. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is insufficient evidence in the literature that this device is effective for your essential 
tremor. The requested item is not the standard of care for this your tremor according to current guidelines. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device (K1018).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx Sensoready pen. 
 
You asked the Plan to pre-approve Cosentyx Sensoready pen. You say that this drug is medically necessary for 
treating arthropathic psoriasis. 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 Cosentyx Sensoready pen.  
 
Benefits for Cosentyx Sensoready pen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.