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

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that TTE is covered when specific 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a history of edema that
was not documented on physical exam. He has no cardiac symptoms, a normal electrocardiogram, and a recent
normal nuclear stress test. There is no documented covered indication for a TTE and the services are not
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a transthoracic echocardiogram (TTE).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for WATS3D esophageal brush biopsy testing provided on
December 31, 2019.
You asked the Plan to pay for laboratory test. You say that this testing is indicated in addition to routine
endoscopy when the ordering physician determines testing to be medically necessary. The Plan denied your
request. The Plan says the denial of payment for this testing is correct, because this test 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 pay for laboratory test. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found current guidelines recognize the low quality of available evidence in favor of widespread
application of this technique, suggesting only conditionally that WATS3D be reserved for cases of known or
suspected Barrett's esophagus. The records do not support a high likelihood of Barrett's esophagus, and thus do
not meet the guidance relative to medical necessary use of this testing.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of laboratory test have not been met. Therefore, we decided that the Plan does not
have to pay for WATS3D esophageal brush biopsy testing provided on December 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine HCl.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Hydroxyzine HCl.
Benefits for these services 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 inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested 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 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. Our
physician reviewer found you required minimal assistance for sit to stand. You had decreased activity tolerance
and fair endurance. The complexity of your nursing, medical and rehabilitation needs do not require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not
currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple
therapies such as physical and occupational therapy but the documentation does not support that your
functional status requires an 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has an enlarged prostate
gland and elevated serum prostate specific antigen (PSA) level. The documentation includes an office note
from February 2020. There is no discussion of a treatment plan, clinical concern, or rationale for the requested
MRI. The records do not support that the MRI is reasonable and medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve magnetic resonance imaging (MRI) of the pelvis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for selective catheter placement (36246) and endovascular repair (34707) provided on November 22, 2019.
You asked the Plan to pay for selective catheter placement and endovascular repair. You say that these codes are shown in the records. The Plan denied your request. The Plan says these 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 code 36246 is selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family and 34707 is endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation). 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 selective catheter placement and endovascular repair. Our reviewer says that these codes are not supported. Our physician reviewer found the operative report does not clearly document that selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family and endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation) were performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of selective catheter placement and endovascular repair have not been met. Therefore, we decided that the Plan does not have to pay for selective catheter placement (36246) and endovascular repair (34707) provided on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the oropharyngeal suction catheter and supplies (A4628 and
E1399) provided on February 19, 2019.
You asked the Plan to pay for the supplies. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted does 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 A4628 is Oropharyngeal suction catheter, each.
The CPT Code Manual definition of code E1399 is durable medical equipment, miscellaneous.
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 supplies. Our reviewer says that CPT code A4628 does
not meet criteria for billing or reimbursement consideration. The submitted report does not indicate that
oropharyngeal suction was performed. Our reviewer found CPT code E1399 does not meet criteria for billing
or reimbursement consideration. The anesthesia report does not indicate that end tital CO2 sensors were used.
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 supplies have not been met. Therefore, we decided that the Plan does not
have to pay for the oropharyngeal suction catheter and supplies (A4628 and E1399) provided on February 19,
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from February 10, 2020 to February 12, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the $790 charge is for an overnight stay. You say you would like the bill looked at. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 a $395 copayment per day for days 1 through 4 for inpatient hospital care. You have been asked to pay a $395 copayment for each day of the inpatient hospital stay. ($395 x 2 = $790). The inpatient hospital stay falls within the "Inpatient hospital 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 the inpatient hospital stay provided from February 10, 2020 to February 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that daily skilled care will be necessary after
discharge from the hospital. The Plan denied your request. The Plan says the enrollee is able to ambulate
independently and has no complex wound care needs. His needs are mainly custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who was
admitted with leg cellulitis, scrotal swelling, and pain in the presence of ascites due to alcoholic cirrhosis. The
patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled
professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a
SNF. The patient's wound is chronic and the wound care is not complex. He does not have any SN SNF needs.
His functional level does not require skilled therapy services with the specialized skill, knowledge and
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable
treatment in a SNF. He does not require skilled nursing or skilled therapy services (or a combination of these
services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services
on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for a total of 92 miles per trip.
You asked the Plan to pre-approve additional mileage for a total of 92 miles per trip. You say that the
additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage
exceeds the benefit limit. Therefore, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when each one-way trip does not exceed 75 miles.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional mileage for a total of 92 miles per trip.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kyprolis.
You asked the Plan to pre-approve Kyprolis. You say that Kyprolis is medically necessary. The Plan denied
your request. The Plan says this use is considered investigation and is not covered.
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 Kyprolis. Our reviewer says that
Kyprolis is not medically necessary in this case. Our physician reviewer found the combination of drugs
Kyprolis is to be given with in this case is not FDA approved. There are no studies in the literature or Medicare
approved Compendia to support the use of Kyprolis in this application.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Kyprolis have not been met. Therefore, we decided that the Plan does not have
to pre-approve Kyprolis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99231) provided to the enrollee on
December 27, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says this pre-operative visit was included in the payment for the surgical procedure.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. The billed service, 99231, was
bundled as part of the global surgical fee because it was reported the day prior to the major surgical procedure,
64708. The Global Surgical Package includes evaluation and management visits rendered the day prior to a
major surgical procedure. The same physician billed the surgical procedure, CPT code 64708, on the following
day. However, this claim was not billed with a modifier to show that the evaluation and management service
was separate from the global surgical package. Therefore, we decided that the Plan does not have to pay for
subsequent hospital care (99231) provided to the enrollee on December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 11, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have a copayment because this was a follow-up to an injection in February. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 a $45 copayment per specialist visit. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure or injection.
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 the specialist office visit provided on March 11, 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 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 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. Our
physician reviewer found based on the medical records provided there is concern that the enrollee will not be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this
case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza.
You asked the Plan to pre-approve Amitiza. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Amitiza.
Benefits for Amitiza 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 Radicava for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Radicava for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.