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

 
We decided that the Plan does not have to pre-approve a hip arthroplasty. 
 
You asked the Plan to pre-approve a hip arthroplasty. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are 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 a hip arthroplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for left hip osteoarthritis. The enrollee presented with 
left hip pain. The symptoms began on May 19, 2022 and the pain is rated at 5-6 and is constant. The pain is 
aching, dull, piercing, and sharp. The symptoms are aggravated by bending, sitting, climbing, stairs, movement, 
standing, descending stairs, pushing, walking, household activities, recreational activities, walking on uneven surfaces, turning/pivoting, getting out of a chair, getting in/out of a car, stepping sideways, squatting, kneeling, 
and running. The associated symptoms are limping, pain after inactivity, stiffness, decreased mobility, wake at 
night, pain at night, difficulty going to sleep, weakness, joint tenderness, and popping. The exam reveals mildly 
tender to palpation of the greater trochanter. There is pain with log roll. The flexion is greater than 95 degrees, 
abduction 30-59 degrees, adduction is 30-59 degrees, internal rotation 30-59, and external rotation 30-59. X-
rays are noted to show moderate to severe joint space narrowing near the superior acetabular rim; osteophyte 
formation noted at the femoral head/neck junction. However, detailed documentation is not evident regarding 
trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. The 
enrollee went to an initial evaluation for physical therapy. However, there is no updated documentation 
supporting the failure of that therapy. Additionally, the enrollee has not tried any injections for the hip. The x-
rays were noted on the exam to show moderate to severe joint space narrowing. However, there were no formal 
diagnostic reports provided for review. There are limited large-scale, long-term references showing the safety 
and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
enrollee does not meet criteria for the requested 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 a hip arthroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a hip arthroplasty.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 29, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 24, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on February 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an x-ray provided on February 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does have documented skilled nursing needs, in the form of a new 
ostomy. There is no evidence that the enrollee or family has successfully completed ostomy teaching. It does 
not appear that the enrollees spouse will be able to assist with ostomy care. The enrollee also has documented 
skilled therapy needs, as he appears to be functioning below his baseline. While ambulatory, he does not appear 
to be safe or steady.  Daily skilled services are required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
   
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance spectroscopy (MRS) (76390). 
 
You asked the Plan to pre-approve an MRS. The Plan denied your request. The Plan says this procedure is not 
reasonable or 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 an MRS. Our reviewer says that the 
requested MRS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found a magnetic resonance spectroscopy (MRS) is not routinely indicated in the evaluation of brain tumors 
but can provide useful additional noninvasive data in selected cases, especially when the imaging appearance is 
equivocal and non-neoplastic etiologies are under consideration. MRS data also correlate with tumor type and 
grade but are not sufficiently sensitive or specific to replace histologic diagnosis. Our reviewer also found that 
this enrollee had a lesion suspicious for disease on the magnetic resonance imaging from April 29, 2022, and 
no clear indication why an MRS is needed. 
 
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 MRS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance spectroscopy (MRS) (76390).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from January 18, 2021, to 
October 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that the procedure should have been filed as 
medical. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The file shows that a surgical implant and sinus augmentation were provided. Although the Plan offers a dental 
benefit in excess of Medicare coverage, these services are not among those covered under this benefit. Your 
dental benefit does cover anesthesia services; however, they are not covered when provided with non-covered 
services. Therefore, we decided that the Plan does not have to pay for the dental services provided from 
January 18, 2021, to October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk and need IRF care. The Plan 
denied your request. The Plan says the records do not show that the enrollee needs an intensive team for their 
care. The services the enrollee needs can be provided safely in other settings like a skilled nursing facility 
(SNF), home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs identified or 
documented. At the current functional mobility, will not be able to tolerate the intensity of IRF and the enrollee 
does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. IRF admission is not medically necessary based lack of medical 
complexity and acute rehabilitation nursing needs and inability to tolerate. 
 
Documentation does not support the medical necessity for admission to an IRF. While the enrollee may benefit 
from continued physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely 
provided in a lower intensity and alternate setting such as in an SNF. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
can be received 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 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test and sales tax received on January 18, 
2022. 
 
You asked the Plan to pay for the COVID-19 test and sales tax. You say that you disagree with the denial of 
payment. The Plan denied your request. The Plan says the items received are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for over-the-counter COVID-19 tests 
obtained prior to April 4, 2022 are not covered.  
 
We looked at the file and Medicare rules. Review of the file shows that you received the COVID-19 test prior 
to April 4, 2022. This means this item is not a covered benefit. Based on this information, we decided that 
Medicare rules for coverage of the COVID-19 test and sales tax have not been met. Therefore, we decided that 
the Plan does not have to pay for the COVID-19 test and sales tax received on January 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on November 4, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you have provided supporting documentation for 
the test that were ordered. The Plan denied your request. The Plan says that 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 G0841 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., 
ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0841 is supported in the medical record. Specifically, the documentation does support 
that there was at least 8+ drug classes that were tested. Based on this information, we decided that Medicare 
rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay for the 
drug testing provided on November 4, 2021. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the ventilator is to be used for the 
treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
with settings that could be delivered by BiPAP with AVAPS for this member with COPD is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure from chronic obstructive pulmonary disease. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens (V2781) provided on April 23, 2022. 
 You asked the Plan to pay for the progressive lens. You say that you have been reimbursed for the purchase of 
progressive lenses in the past. The Plan denied your request. The Plan says your coverage does not provide for 
this service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover upgrades, including progressive lenses. 
 
We looked at the file and the Plan's rules. The record shows you received progressive lenses, which are not 
covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of the progressive 
lens have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens 
(V2781) provided on April 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition, they do not 
meet all the requirements. 
 
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. Our 
physician reviewer found the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.