Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no instability on an exam on 10/27/20. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is ambulatory, but the documentation does not reveal objective findings of knee instability. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1852).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PVA, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; thoracic (CPT Code 22513). 
 
You asked the Plan to pre-approve the PVA. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 PVA. Our physician reviewer found 
the criteria for compression fracture are not met. There is no evidence that the fracture is less than six (6) weeks 
old. 
 
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 PVA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PVA, including cavity creation (fracture reduction and bone biopsy included when performed) 
using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all 
imaging guidance; thoracic (CPT Code 22513).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services provided to the enrollee on April 
21, 2019 and billed under codes G0283, 97112 and 97140. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the documentation did not include the time spent with the enrollee which is required for 
the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 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 these services. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer 
found the records provided do not support the services billed. The required time element is not appropriately 
documented. 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 pay for outpatient therapy services provided to the enrollee on April 21, 2019 and billed 
under codes G0283, 97112 and 97140.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve a LDCT scan for lung cancer screening. 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. Medicare rules say that a LDCT scan for lung cancer screening is 
covered when specific criteria is met. 
 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a LDCT scan for lung cancer screening have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that your provider indicated that traditional 
chemotherapy would have more of an effect on your immunity than Keytruda. You also say that your provider 
would prefer not to have you undergo chemotherapy at this time. The Plan denied your request. The Plan says 
the requested use of this medication is not considered medically necessary. 
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically reasonable and necessary. Our physician reviewer found you have a diagnosis of 
metastatic non-small cell lung cancer. The review of approved compendia supports the use of Keytruda for 
individuals with this cancer type who also have programmed death-ligand 1 (PD-L1) expression. Our reviewer 
found that the records do not support that you had PD-L1 expression. Keytruda is not supported in the current 
medical literature. Our physician reviewer also found that medical necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) (eg, 
anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle 
or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (62323) triamcinolone acetonide 
injection (J3301) provided January 3, 2020. 
 
You asked the Plan to pay for the injection services. You say that the attached medical record contains a 
detailed account of the history, examination and medical decision making provided. It is your position that the 
documentation supports the E&M level of care billed. The Plan denied your request. The Plan says the records 
do not support the service 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, we find that CPT codes 62323 and J3301 are not supported in the medical record. Specifically, the 
documentation submitted did not include sufficient detail to support the billed charges. Documentation does not 
indicate the name of the servicing provider to support the billed codes. There is insufficient documentation to 
corroborate the services and confirm Medicare coverage has been met. Based on this information, we decided 
that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the 
 
 
Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, lumbar or sacral (62323) triamcinolone acetonide injection 
(J3301) provided January 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility admission.

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 SNF care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 18, 2020 
and billed under code 78803-26. 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says the medical records show the enrollee had tumor localization on June 18, 2020. 
The submitted documentation supports 1 (one) unit of 78803-26, which was previously approved and paid on a 
different claim. There is no additional documentation supporting an additional study which was billed and 
remains denied.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the services billed were previously paid 
on another claim. The claim in question is not shown to be a separate and distinct service. Based on this 
information, we decided that Medicare rules for coverage of this service have not been met.  
 
 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
June 18, 2020 and billed under code 78803-26.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Eliquis.  
 
Benefits for Eliquis 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment. 
 
You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 inpatient mental health treatment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based upon review of the records provided, this patient does not meet the 
criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 7, 
2020 forward and could have been treated in a lesser restrictive setting. The enrollee was not showing any 
suicidal or homicidal ideation, auditory or visual hallucinations, or delusions and was not showing any 
behaviors or aggression. The enrollee was being cooperative and compliant while not showing any acute 
threats to the safety of themselves or others. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth debridement (D4355). 
 
You asked the Plan to pre-approve the full mouth debridement. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says the member rendered 
services for a comprehensive oral evaluation (D0150) on September 18, 2020, exhausting the member?s benefit 
for 1 per 3 calendar years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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. Specifically, the record indicates that you received a comprehensive 
oral evaluation (D0150) on September 18, 2020. The Plan contract states that the requested service cannot be 
performed on the same day or less than one calendar year from the comprehensive oral evaluation. Therefore, 
we decided that the Plan does not have to pre-approve full mouth debridement (D4355).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary closure of a sinus perforation (D7261). 
 
You asked the Plan to pre-approve primary closure of a sinus perforation. You say that the service is necessary. 
The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
primary closure of a sinus perforation (D7261).
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 the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day /5 days 
a week, or 15 hours over 7 consecutive days, of therapy services. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve spinal surgery. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because the enrollee does not have 
documented unacceptable instability, has no rapidly progressing neurologic symptoms, and no findings noted 
on imaging to suggest instability. 
 
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 spinal surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented instability, therefore criteria for fusion are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion surgery.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 
services are not medically necessary. Our physician reviewer found the records show that you were admitted to 
the hospital on November 19, 2020. You underwent heart surgery on November 24, 2020 and are not medically 
stable. You need minimal assistance for sitting up and lying down and contact guard assistance with transfers 
and walking 100 feet. You do not require the intensity services provided at an IRF. Specifically, you do not 
require 15 hours per week of rehabilitative services and regular physician evaluation. 
 
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 home infusion therapy. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home infusion therapy.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level referral for transthoracic 
echocardiography for the enrollee. 
 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's condition is stable and can be managed at the community level. 
 
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 referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have a complex congenital cardiac condition which might necessitate specialized 
tertiary echo services but an ischemic cardiomyopathy and mitral valvular disease. These are routine and 
standard cardiac conditions which can be evaluated and assessed at a community level echo lab and do not 
require a specialized tertiary lab evaluation. The treating practitioner can obtain the report of the study and can 
also personally review the study which can be copied and made available for viewing as well with the 
enrollee's consent. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary level referral for transthoracic echocardiography for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transport rides (W6110). 
 
You asked the Plan to pre-approve the transport trips. You say that the additional trips are medically necessary. 
The Plan denied your request. The Plan says the non-emergency transport benefit has been exhausted. 
 
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 a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The enrollee has used 50 one way trips. 
Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of 
routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transport rides (W6110).