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

 
We decided that the Plan does not have to pre-approve Mycophenolate mofetil oral (J7517). 
 
You asked the Plan to pre-approve Mycophenolate mofetil oral. You say that the enrollee has previously been 
on this medication. The Plan denied your request. The Plan says coverage of this medication is the 
responsibility of the enrollee's prescription drug 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 Mycophenolate mofetil oral 
(J7517).  
 
Benefits for Mycophenolate mofetil oral 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee needs this because of chronic low blood sugar. The Plan denied your request. The Plan says that a CGM is not medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met.
We looked at the file and Medicare rules. The file indicates the enrollee does not have a diagnosis of diabetes. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (CPT 71045-26-77) for date of service March 
18, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that the enrollee had multiple exams on this date of 
service. You say that the attached reports support the level of service. 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. 
 
We find that CPT code  is not supported in the medical record. Specifically, the records do not show that the 
doctor who billed the services in dispute, performed them on March 18, 2020. Based on this information, we 
decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the 
Plan does not have to pay for a chest x-ray (CPT 71045-26-77) for date of service March 18, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the request for inpatient rehab does not meet the criteria because the 
care is not complex enough and does not show it would cause excessive physical hardship for you to receive 
needed care on an outpatient basis or skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. Our physician reviewer found that your condition does not meet Medicare 
criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the 
enrollee on October 29, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the documentation submitted did not include a valid physician order/lab requisition or 
medical records (signed by the ordering physician); therefore, the billed codes cannot be verified 
 
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 the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g.,  utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, 
RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, 
(DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation 
when performed, per date of service 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
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 
services at issue in this case were supported by the medical records. Our physician reviewer found the 
laboratory submitted a valid/signed physician laboratory requisition form and lab results. The review has 
determined that the records support the denied codes. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for EEG monitoring (95951) provided on October 31, 2019. 
 
You asked the Plan to pay for the EEG monitoring. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the professional interpretation of a diagnostic 
test must be separately billed with modifier -26 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 95951 is not supported in the record. Specifically, this claim was billed with place of 
service code 21, indicating that the member was inpatient on the billed date of service. The professional 
interpretation of the EEG must be separately billed with modifier -26 to indicate the professional component. 
Based on this information, we decided that Medicare rules for coverage of the EEG monitoring have not been 
met. Therefore, we decided that the Plan does not have to pay for EEG monitoring (95951) provided on 
October 31, 2019.
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 you would benefit from these services. The Plan 
denied your request. The Plan says that the therapy needs are not inherently complex and do not require an 
interdisciplinary approach. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. You 
are medically stable with no evidence of need for supervision by physical medicine and rehab physician or 
needs acute rehab nursing care. Functionally given your current level, though you need physical therapy (PT) 
and occupational therapy (OT), you do not require IRF level of therapies. IRF admission is not medically 
necessary based on your current functional status and lack of medical complexity. Our physician reviewer 
found that your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.
You asked the Plan to pre-approve this is medically necessary. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
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 Procrit for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by opted out physician on March 9, 2020. 
 
You asked the Plan to pay for office visit. You say that this doctor does not take any insurance, so you had to 
pay out-of-pocket and should be paid by the Plan. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this provider has opted out of Medicare and cannot be paid for this 
service. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
an office visit provided by opted out physician on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp from your porch to your driveway.
You asked the Plan to pre-approve a wheelchair ramp. You say that this is necessary for you to safely leave your home. The Plan denied your request. The Plan says this item is not medical in nature and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp from your porch to your driveway.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body (78816), for the enrollee.
You asked the Plan to pre-approve the PET scan. You say that the initial PET was completed June 2019. The Plan denied your request. The Plan says that the imaging is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 PET scan. Our physician reviewer found aortitis is a very serious diagnosis and PET/CT can provide useful information on response to therapy. This patient having a baseline study will be of great benefit for monitoring response to therapy. Obviously aortitis is very serious and the outcome of failed therapy is catastrophic. Our doctor feels the test is indicated and appropriate. 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body (78816), for the enrollee.
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 24, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
laboratory services. 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 laboratory services provided on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on October 2, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 drug testing services provided on October 2, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 7, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 
laboratory services. 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 laboratory services provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pressure-reducing air mattress.
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of any pressure ulcers.
The Plan must follow Medicare rules. Medicare rules say that a pressure reducing air mattress is covered when certain criteria are 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 the mattress. Our reviewer says that the requested mattress is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of stage II pressure ulcers, large or multiple stage III or IV ulcers, or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. 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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a pressure-reducing air mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress.
You asked the Plan to pre-approve a powered pressure reducing air mattress. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria
for the requested item.
The Plan must follow Medicare rules. Medicare rules say that pressure reducing air mattresses are covered
when the enrollee has multiple stage II pressure ulcers located on the trunk or pelvis, or has large or multiple
stage III or IV pressure ulcer(s) on the trunk or pelvis, or the enrollee had large or multiple stage III or IV
pressure ulcer(s) on the trunk or pelvis.
We looked at the file and Medicare rules. Review of the file does not support that the enrollee has multiple
stage II pressure ulcers located on the trunk or pelvis, or has large or multiple stage III or IV pressure ulcer(s)
on the trunk or pelvis, or the enrollee had large or multiple stage III or IV pressure ulcer(s) on the trunk or
pelvis. Based on this information, we decided that Medicare rules for coverage of a powered pressure reducing
air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered
pressure reducing air mattress.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT), thorax; without contrast material 
(71250), for the enrollee. 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says that the CT scan is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our physician reviewer 
found the provider is looking for evidence of pulmonary fibrosis that may not be present on plain film chest x-
ray. Meaning a chest x-ray showing potential fibrosis still would warrant a CT and a negative chest x-ray 
would not mean patient does not have pulmonary fibrosis. The chest x-ray is not integral to decision to perform 
CT. Our doctor feels the test is reasonable given prior result on pulmonary function 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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT), thorax; without contrast material (71250), for the enrollee.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services were not supported.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 drug testing services provided on July 9, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen test for the enrollee. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary because the records indicate that this test is being used to 
diagnose SIBO. 
 
The Plan must follow Medicare rules. Medicare rules say that breath hydrogen tests are not covered to diagnose 
SIBO. 
 
This test is being requested to diagnose SIBO. Based on this information, we decided that Medicare rules for 
coverage of the test have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
breath hydrogen test for the enrollee.