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

 
We decided that the Plan does not have to pay for laboratory testing panel provided on May 27, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because these tests are not a Medicare 
benefit for the diagnosis listed and were done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
There is no documentation in the record of a specific concern for which this testing was ordered. The records 
do not include any lab order showing that the results of this testing were needed to diagnose or treat a medical 
condition. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the 
Plan does not have to pay for laboratory testing panel provided on May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 4, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 codes 80157, 80177, 80201, 80162, 80159, 80173, are not supported in the medical record. 
Specifically, the submitted toxicology request form indicates the specimen was urine. However, the services in 
question were performed on a blood specimen collected by venipuncture. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve spinal surgery. You say that the requested spinal surgery is medically 
necessary. The Plan denied your request. The Plan says the requested spinal surgery is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve spinal surgery. Our reviewer says that 
the requested spinal surgery is not medically necessary. Our physician reviewer found the enrollee is diagnosed 
with low back pain. Criteria for lumbar fusion have not been met. There is no documented spinal instability on 
imaging showing greater than 5mm of abnormal segment motion. Spine fusion is not medically needed 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 spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clonidine hydrochloride, 1MG injection (CPT Code J0735) 
and hydromorphone, up to 4MG injection  (CPT Code J1170) provided on January 28, 2020. 
 
You asked the Plan to pay for the injections. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Healthcare Common Procedure Coding System (HCPCS) code J1170 (75 Units) remains not supported. The 
documentation submitted did not include an itemized shipping/billing invoice from the billing provider to 
indicate this billed supply and units. Therefore, the billed supply code cannot be verified. It is noted that 
multiple attempts were made to contact the provider for additional information. 
 
Healthcare Common Procedure Coding System (HCPCS) code J0735 (15 Units) remains not supported. The 
documentation submitted did not include an itemized shipping/billing invoice from the billing provider to 
indicate this billed supply and units. Therefore, the billed supply code cannot be verified. It is noted that 
multiple attempts were made to contact the provider for additional information.  
 
Based on this information, we decided that Medicare rules for coverage of the injections have not been met. 
Therefore, we decided that the Plan does not have to pay for clonidine hydrochloride, 1MG injection (CPT 
Code J0735) and hydromorphone, up to 4MG injection  (CPT Code J1170) provided on January 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include respiratory support with oxygen supplementation, anticoagulation, telemetry, surveillance 
laboratory studies, and therapy services. 
 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET/CT scan. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Medicare does not cover PET imaging for initial anti-
tumor strategy for prostate cancer patients. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that PET 
imaging for initial anti-cancer strategy is non-covered for enrollees with prostate cancer. Therefore, we decided 
that the Plan does not have to pre-approve a PET/CT scan.
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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with cerebral vascular 
accident and right hemiparesis, now in an IRF. From a nursing perspective, the enrollee received oral 
medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received 
physical therapy, speech therapy and occupational therapy in the acute hospital. The enrollee was at a moderate 
to maximal assist level including gait to 50 feet x 3.  The enrollee required varying assist with activities of daily living. She worked with speech therapy on cognitive-linguistic deficits. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis.  This enrollee does 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 admission to a SNF 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ernesto tablets. 
 
You asked the Plan to pre-approve Ernesto tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Ernesto tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Ernesto tablets.  
 
Benefits for Ernesto tablets 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used 22 of the 24 allotted trips 
for the 2020 benefit year. 
 
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 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The Plan covers 24 one-way trips per 
year. The file shows that you have used 22 of the 24 allotted trips. You have 2 trips remaining and then you 
will have exhausted your routine transportation benefit. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation.
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. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include respiratory support with oxygen supplementation, telemetry monitoring, surveillance 
laboratory studies, close fluid balance,  and therapy services. 
 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the requested Opdivo is medically necessary. The 
Plan denied your request. The Plan says the requested Opdivo is not 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 Opdivo. Our reviewer says that the 
requested Opdivo is not medically necessary. Our physician reviewer found the enrollee is diagnosed with 
metastatic GE junction adenocarcinoma. Opdivo is not FDA-approved for the enrollee's diagnosis. The use of 
Opdiva is not supported in any of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional office visits to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve additional office visits. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network providers available to you 
that can provide the care and treatment you are requesting. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
additional office visits to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested spinal store stimulator is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a 
spinal cord stimulator. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a spinal cord stimulator. Our reviewer 
says that the enrollee does not meet criteria for a spinal cord stimulator. Our physician reviewer found the 
enrollee has chronic low back pain. She has had physical therapy, heat/ice, rest and NSAIDs. On MRI she has 
degenerative disc disease and facet joint disease. She had a psychological evaluation and was cleared for a SCS 
trial. The enrollee doesn't have an evidence based indication for a spinal cord stimulator trial.  The request is 
not medically reasonable or 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
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 in this case, the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesn't support that the enrollee would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain their functional status. The enrollee is ambulating 
up to 50 feet with minimal assistance. The enrollee has been medically stable, and there are no skilled nursing 
consults. The enrollee can receive therapy at a lower level of 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coronary Computed Tomography Angiography 
(CCTA) (75574). 
 
You asked the Plan to pre-approve the CCTA imaging. You say that the CCTA is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 CCTA imaging. Our reviewer says 
that the requested CCTA is not medically necessary. Our physician reviewer found the results of the stress 
nuclear scan are reported as abnormal and clearly positive for cardiac ischemia with stress in this symptomatic 
patient. ACC/AHA appropriate use criteria do not endorse the use of cardiac CTA prior to cardiac 
catheterization and angiography in this situation when the nuclear stress test is reported as clearly positive for 
ischemia in a symptomatic patient. 
 
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 CCTA imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Coronary Computed Tomography Angiography (CCTA) (75574).