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

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve continued inpatient psychiatric hospital services. You say that these services 
are medically necessary. The Plan denied your request. The Plan says that treatment can continue safely at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric hospital 
services. Our reviewer says that continued inpatient psychiatric hospital services are not medically reasonable 
and necessary for the enrollee in this case. You do not appear to require continued inpatient mental health 
treatment as you are not a danger to yourself or others, have no auditory hallucinations or visual hallucinations 
while being cooperative with treatment. It does not appear that active treatment is taking place. It does not 
appear that the services are reasonably expected to improve your condition or for the purpose of diagnosis. Our 
physician reviewer found that your condition does not meet Medicare criteria for continued inpatient 
psychiatric hospital 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 continued inpatient psychiatric hospital services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve the testing. You say that additional information is needed to see if breast 
cancer runs in the family. The Plan denied your request. The Plan says Medicare does not cover BRCA genetic 
testing with no personal history of cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the testing, is being requested solely for screening purposes. There is no 
personal history of cancer. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pre-approve BRCA genetic testing.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. 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 HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the records do not 
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to 
improve your condition, or to establish/perform a maintenance program to maintain your condition and/or 
prevent deterioration. There is no evidence of complex wound care or other skilled nursing (SN) need. The 
records do not show that skilled therapy is needed to effectively provide treatment, care, and/or services in 
order to improve your level of function, or to establish/perform a maintenance program to maintain your level 
of function and/or prevent deterioration.  As you do not require skilled therapy or skilled nursing services, you 
do not meet the definition of home health aide services per Section 50.2 and the request for home health aide 
services are not reasonable and necessary to the treatment of your illness or injury by the skilled professional 
staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tab 2.5mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication does not fall under Part B. 
 
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 tab 2.5mg for the 
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power operated vehicle. 
 
You asked the Plan to pre-approve the group 1 power operated vehicle. You say that you have severe 
osteoarthritis in both knees, very poor stability, and cannot walk or stand for long periods of time. You say that 
you are at the end stages of the diagnosis and that there is nothing more that can be done. You say that you 
want to be able to get around safely and without fear of falling. You say that the walker you have been using is 
not enough to help your severe pain. The Plan denied your request. The Plan says the clinical information 
provided does not show that the guidelines for coverage have been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 group 1 power operated vehicle. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
documentation provided does not support that the enrollee has a personal mobility deficit that impairs 
participating in mobility related activities of daily living (MRADLs). The records show that the enrollee uses a 
walker but do not demonstrate that the enrollee has a limitation that significantly impairs her ability to 
participate in activities such as toileting, feeding, dressing, grooming, and bathing in customary locations 
within the home. 
 
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 group 1 power operated vehicle have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 1 power operated vehicle.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper endoscopy. 
 
You asked the Plan to pre-approve the endoscopy. You say that this is medically necessary. The Plan denied 
your request. The Plan says the documentation received fails to indicate an appropriate trial of therapy for 
abdominal distress. 
 
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 endoscopy. Our reviewer says that 
the requested endoscopy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that symptoms of dyspepsia are refractory to an appropriate 8-12-
week trial of PPI therapy. The negative results of a colonoscopy have not been provided. 
 
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 endoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an upper endoscopy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs subacute rehab to maximize 
her functional recovery. The Plan denied your request. The Plan says the enrollee is at her functional baseline. 
 
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 services. Our physician reviewer 
found that the enrollee is dependent for bed mobility, transfers and everyday activities. She is non-ambulatory. 
She remains at her functional baseline and does not require skilled physical therapy services at this time. There 
is no indication for skilled occupational therapy intervention as this time. She does not require skilled nursing 
or skilled therapy services on a daily basis in a SNF. As a practical matter, this enrollee 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Atezolizumab and Nab-Paclitaxel. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says it is not 
indicated that the enrollee has triple negative disease. 
 
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 the requested drugs. Our physician 
reviewer found that this review relates to a request for Atezolizumab to be given with Nab-paclitaxel to treat a 
hormone receptor positive, HER2 negative metastatic breast cancer. The combination requested is not FDA 
approved for hormone receptor positive breast cancer. The combination is not supported in any of the CMS 
approved compendia. There is no evidence of any supporting citations in a PubMed search. The use is not 
listed as not recommended, not indicated or not supported in any of the compendia. The documentation does 
not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Atezolizumab and Nab-Paclitaxel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on May 15, 2020. 
 
You asked the Plan to pay for the nurse practitioner 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 
services at issue. 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 nurse practitioner services provided on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery and coinsurance for 
an injection provided by a participating provider on March 10, 2020 to March 13, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery and coinsurance for an injection. You say 
that you normally only get charged $95 twice. You say that you think that this has been charged incorrectly. 
The Plan denied your request. The Plan says the correct copayment and coinsurance have been applied. 
 
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 $95 
copayment for outpatient surgery/in-network and a 20% coinsurance for Medicare Part B prescription drugs/in-
network.  
 
You have been asked to pay a $95 copayment for each outpatient surgery and a 20% coinsurance of the 
allowed amount for an injection. The total amount you are being asked to pay for outpatient surgeries is $190 
($95 x 2 surgeries = $190). The total amount you are being asked to pay for injections is $212.56, which is less 
than your 20% coinsurance, ($1,084.10 x 20% = $216.82). The total amount you are being asked to pay is 
$402.56 ($190 + $212.82 = $402.56). An outpatient surgery falls within the outpatient surgery/in-network 
benefit category and an injection falls within the Medicare Part B prescription drugs/in-network 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 and coinsurance for an outpatient surgery and an 
injection provided by a participating provider on March 10, 2020 to March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00142x36) provided on January 20, 
2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation does not support the units 
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 00142x36 is anesthesia for procedures on eye; lens 
surgery. 
 
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 anesthesia services. Our reviewer says that CPT code 
00142x36 does not meet criteria for billing or reimbursement consideration. Our reviewer found CPT 00142 is 
billed at 1 unit per 15 minutes with a base unit of 4. The medical records submitted do not support 36 units of 
00142 being administered on January 20, 2020, therefore this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (00142x36) provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 2, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
physician's 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 physician's services provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the digital analysis of an 
electroencephalogram (EEG) provided on August 13, 2019 billed with code 95957-26. 
 
You asked the Plan to pay for the billed EEG interpretation services. You say that these codes were correctly 
reported and should be paid for the services rendered. The Plan denied your request. The Plan says as there 
were no spikes recorded in the EEG, it is not appropriate to bill for digital analysis of spikes. 
 
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 95957 is Digital analysis of electroencephalogram (EEG) 
(eg, for epileptic spike analysis). 
 
We asked our coding 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 billed EEG interpretation services. Our 
reviewer says that the documentation does not support payment for code 95957. Our coding reviewer found the 
medical records provided do not include documentation of a digital analysis of electroencephalogram (EEG) 
(eg, for epileptic spike analysis) being performed August 13, 2019 as the records do not show any spikes to 
analyze, therefore it is inappropriate to report CPT 95957. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed EEG interpretation services have not been met. Therefore, we decided 
that the Plan does not have to pay for the interpretation of the digital analysis of an electroencephalogram 
(EEG) provided on August 13, 2019 billed with code 95957-26.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on October 11, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 95861 is not supported. 
 
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 95861 is needle electromyography; 2 extremities with or 
without related paraspinal areas. 
 
We find that CPT code 95861 is not supported in the medical record. Specifically, the documentation supports 
that a free running electromyography was performed, not a needle electromyography. 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 the testing services rendered on October 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intensive outpatient psychiatric services rendered from 
October 18, 2019 to October 31, 2019. 
 
You asked the Plan to pay for 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 a status indicator of I represents a code that is not valid 
for Medicare purposes. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code S9480. This code 
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not 
have to pay for the intensive outpatient psychiatric services rendered from October 18, 2019 to October 31, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing rendered on April 30, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 the Guardant360 testing rendered on April 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the midazolam hydrochloride injection. 
 
You asked the Plan to pay for the injection. 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 
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, the CPT Code Manual definition of code J2250 is injection, midazolam hydrochloride, per 1 mg. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the injection. Our reviewer says that CPT code J2250 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided 
do not include documentation of an Injection, midazolam HCl, per 1 mg being performed on January 30, 2020, 
therefore this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the midazolam hydrochloride injection.