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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute 
care facility. 
 
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 LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be improving but requires additional short term acute care services of less than 25 days to continue 
wound care and antibiotics. The patient does not require services at the LTACH that are not already being 
provided at the current setting. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery on the lower spine to include fusion.

You asked the Plan to pre-approve the services. You say that the patient has a prior history of lumbar fusion and now has adjacent segment disease and you are concerned that the prior region of surgery has a pseudoarthrosis. You state the patient has severe and unremitting back and leg pain symptoms and they have failed medical management. You state you have recommended surgical decompression and fusion from L3-L5 given the severe symptoms. The Plan denied your request. The Plan says the surgery is not medically necessary at this time.

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 physician reviewer found the criteria for revision surgery and fusion are not met. There is no documented instability or failure of previous fusion as shown by a computed tomography (CT) scan. More information is needed to justify revision surgery.

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 surgery on the lower spine to include fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Morphine Sulfate (J8499). 
 
You asked the Plan to pre-approve Morphine Sulfate. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Morphine Sulfate (J8499).  
 
Benefits for Morphine Sulfate 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the shoulder 
(73221). 
 
You asked the Plan to pre-approve an MRI of the shoulder. 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 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 an MRI of the shoulder. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee had a 
telemedicine visit on September 14, 2020. Physical exam has not been done recently. X-rays have not been 
done since 2014.  Absent a physical exam, the presence of a red flag to mandate immediate MRI without a 6 
week course of conservative therapy including physical therapy (PT) has not been addressed. Absent such an 
exam and documentation, the medical necessity of an MRI without a conservative trial of therapy has not been 
established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the shoulder have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the shoulder (73221).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aid (CPT Code V5257-LT) purchased on 
October 25, 2019. 
 
You asked the Plan to pre-approve the hearing aid. You say that you were told the denial was because they did 
both ears on the same day. The Plan denied your request. The Plan says they have limited benefits for hearing 
aids which was paid on the code V5257-RT for the same date of service. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met.  
 
You exhausted your maximum benefit allowance. Your plan has a maximum benefit of $1000 for hearing aid 
services every 3 years. This benefit was paid on this claim. The claim total was $4398 for hearing aid services, 
the plan has paid the maximum benefit of $1000 as outlined in your plan benefits. Therefore, we decided that 
the Plan does not have to pre-approve hearing aid (CPT Code V5257-LT) purchased on October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair. 
 
You asked the Plan to pre-approve a bath/shower chair. You say that the enrollee has a diagnosis of Parkinson's 
disease and the requested item is medically necessary. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for professional services for the supervision of preparation and 
provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) (CPT 
Code 95165 (10 units)) provided on November 7, 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 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. 
 
Current Procedural Terminology (CPT) code 95165-59 (1 units) remains not supported. The documentation 
submitted did not include a procedure report detailing that professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens was performed; 
therefore, the service including modifier and units 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 services have not been met. Therefore, we decided that the Plan does not have to pay 
for professional services for the supervision of preparation and provision of antigens for allergen 
immunotherapy; single or multiple antigens (specify number of doses) (CPT Code 95165 (10 units)) provided 
on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine. 
 
You asked the Plan to pre-approve Lidocaine. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Lidocaine is 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 Lidocaine.  
 
Benefits for Lidocaine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute. 
 
You asked the Plan to pre-approve a crutch substitute. You say that you cannot have any weight bearing for the 
next four months and a standard walker or crutches will not allow for this. The Plan denied your request. The 
Plan says that Medicare guidelines say that there is insufficient published clinical literature demonstrating 
safety and effectiveness in the Medicare population to establish the medical necessity for crutch substitutes. 
 
The Plan must follow Medicare rules. The DME MAC has determined that there is not sufficient evidence to 
support the medical necessity of a knee scooter at this time. Therefore, we decided that the Plan does not have 
to pre-approve a crutch substitute.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that if the enrollee does not receive therapy that is 
required it will jeopardize his future well being. The Plan denied your request. The Plan says that the enrollee 
can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee is generally medically stable with no evidence of medical or nursing needs for an IRF and his current 
functional status does not require IRF level of therapies. There is no evidence of medical issues that require 
monitoring by an inpatient rehab physician three times a week. The documentation does not support that there 
is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. 
At max assist of 2 for all mobility, he is not expected to make a significant functional recovery in a predicted 
period of time and he has no medical complexity. His rehab needs can be safely and effectively met in an 
alternate, less intense setting. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical 
services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and 
management of an established patient, typically, 25 minutes are spent face-to-face with the patient and/or 
family (CPT Code 99214) provided on January 13, 2020. 
 
You asked the Plan to pay for the services. You say that the claim is not a duplicate and should be reconsidered 
for payment. The Plan denied your request. The Plan says this is a duplicate of a charge considered on a 
previous claim. 
 
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. This is a duplicate to another claim, 
billed for 99214, both with matching date of service, provider and diagnosis codes. Therefore, we decided that 
the Plan does not have to pay for office or other outpatient visit for the evaluation and management of an 
established patient, typically, 25 minutes are spent face-to-face with the patient and/or family (CPT Code 
99214) provided on January 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right heart catheterization. 
 
You asked the Plan to pre-approve right heart catheterization. You say that the requested right heart 
catheterization is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested right heart catheterization. 
 
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 right heart catheterization. Our reviewer 
says that the enrollee does not meet criteria for the requested right heart catheterization. Our physician reviewer 
found the enrollee is with a history of malignant peripheral nerve sheath tumor being treated with 
chemotherapy and with left upper extremity swelling due to axillary tumor. A clinic note dated 09/08/2020 
does not document any chest pain or dyspnea. Anemia (Hct 25) and mild hypotension noted. 
 
Based on the records provided the enrollee has no documented heart or pulmonary disease and is being treated 
for nerve sheath tumor leading to left upper extremity edema.  In this circumstance the documentation does not 
support the medical necessity for right heart catheterization.  Coverage criteria are not met since there are no 
documented covered indications for the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve right heart catheterization.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 perivascular epithelioid cell (PEComa) 
is a rare tumor but recommendations are for a clinical trial or sirolimus. FDA approval is for the treatment of 
unresectable or metastatic, microsatellite instability-high (MSI-H) or mismatch repair-deficient (dMMR) solid 
tumors in adult and pediatric patients that have progressed following prior treatment and have no satisfactory 
alternate treatment options. The enrollee has not received first line therapy. Therefore, the service is 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 Keytruda.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tubal ligation for an elective sterilization. 
 
You asked the Plan to pre-approve tubal ligation for an elective sterilization. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says this is not a covered benefit under 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that elective hysterectomy, tubal ligation, and vasectomy, 
if the primary indication for these procedures is sterilization, are not covered. The file shows that the enrollee is 
requesting this procedure due to the desire for no pregnancies. Therefore, we decided that the Plan does not 
have to pre-approve tubal ligation for an elective sterilization.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a lumbar interspinous process stabilization 
device (22869). 
 
You asked the Plan to pre-approve insertion of a lumbar interspinous process stabilization device. 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 insertion of a lumbar interspinous 
process stabilization device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research 
is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a lumbar interspinous process stabilization device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve insertion of a lumbar interspinous 
process stabilization device (22869).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SOZO bioimpedance spectroscopy (93702). 
 
You asked the Plan to pre-approve a SOZO bioimpedance spectroscopy. 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 a SOZO bioimpedance spectroscopy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a diagnosis of invasive ductal carcinoma, arthritis, and 
obesity. Review of approved compendia notes the use of bioimpedence spectrscopy for the early diagnosis and 
treatment management of lymphedema continues to be in the investigational stage of development. Without the 
support of the literature, 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 a SOZO bioimpedance spectroscopy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a SOZO bioimpedance spectroscopy (93702).