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

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve epidural steroid injection. You say that the enrollee previously had 
significant pain relief from an epidural. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because there is no documented failure of physical therapy or a home exercise 
program. 
 The Plan follows Medicare rules. Medicare rules state that epidural steroid injections are only covered if certain 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural steroid injection. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested epidural steroid injection. Our 
physician reviewer found the enrollee has to have a course of physical therapy or home exercise program, or a 
reason why the enrollee cannot participate in either must be clearly documented. Given the lack of participation 
in physical therapy or a home exercise program the request is not medically necessary or reasonable 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 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. Medicare rules say that cardiac monitoring is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of 
bradycardia and hypertrophic cardiomyopathy. There is no documentation provided to suggest a history of 
unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ILR in this enrollees clinical 
management. 
 
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 an implantable loop recorder (ILR).
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 does 
not meet criteria. 
 
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 appears to be improving and should only require short-term additional 
acute care services that can be safely administered at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH 
is not medically necessary as it would not be clinically advantageous. 
 
 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided 
from April 1, 2021, to April 8, 2021. 
 
You asked the Plan to pay for the LTACH services. You say that a retro authorization should be approved. You 
also say that the admission was medically necessary. The Plan denied your request. The Plan says the 
admission was 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 pay for 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 does not require services at the LTACH that are not already available at the skilled 
nursing facility (SNF) or a lower level of care.  The reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the SNF. The reviewer also found that transfer to LTACH is not medically necessary 
as it would not have been clinically advantageous. 
 
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 pay for long term acute care hospital (LTACH) services provided from April 1, 2021, to April 
8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
16, 2021. 
 
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 70450 is bundled into payment for 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 December 16, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Capecitabine 500 and Nivolumab (J8521, J299). 
 
You asked the Plan to pre-approve Capecitabine 500 and Nivolumab. You say that these drugs are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Capecitabine 500 and Nivolumab. Our 
reviewer says that these drugs are not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of metastatic esophageal adenocarcinoma. The record indicates that the 
enrollee has received previous chemotherapy and radiation. The Food and Drug Administration has not stated 
that the requested drug regimen is indicated for the enrollee's specific clinical condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's specific clinical situation. No literature from Medicare approved cancer journals were submitted for 
review.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Capecitabine 500 and Nivolumab have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Capecitabine 500 and Nivolumab (J8521, J299).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services of a home health aide (HHA) (G0156), direct 
skilled nursing services of a registered nurse (RN) (G0299), and direct skilled nursing services of a licensed 
practical nurse (LPN) (G0300). 
 You asked the Plan to pre-approve the services of a HHA and direct skilled nursing services of an RN and 
LPN. The Plan denied your request. The Plan says the documentation submitted indicates this request is 
custodial in nature and does not support medical necessity. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 of a HHA and direct skilled 
nursing services of an RN and LPN. Our reviewer says that the requested home health services are not 
medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs. Our reviewer also found that the enrollee does not have documented skilled therapy 
needs. 
 
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 of a HHA and direct skilled nursing services of an RN and LPN 
have not been met. Therefore, we decided that the Plan does not have to pre-approve services of a home health 
aide (HHA) (G0156), direct skilled nursing services of a registered nurse (RN) (G0299), and direct skilled 
nursing services of a licensed practical nurse (LPN) (G0300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (80307 and G0483) provided on 
October 27, 2020. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate POS code. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the drug testing services (80307 and G0483) provided on October 27, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel services provided on April 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that the test was medically necessary. The Plan 
denied your request. The Plan says the billed codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. This claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. The gene panel was also billed with multiple 
codes. If a single procedure is performed, only one code with one unit of service may be reported for the 
procedure. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel services 
provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride excluding varnish (D1208) 
provided on November 19, 2021. 
 
You asked the Plan to pay for the topical application of fluoride excluding varnish. You say that you were 
advised that fluoride treatments were covered. The Plan denied your request. The Plan says this service is 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical application of fluoride excluding varnish (D1208) provided on November 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on December 22, 
2021 
 You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 76700 
and 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76700) provided on December 22, 
2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on April 30, 2021. 
 
You asked the Plan to pay for therapeutic activities. You say that the enrollee received multiple services on the 
date in question, and these services were necessary. The Plan denied your request. The Plan says a National 
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 92526 and 97530. This 
PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service was not billed as required by 
Medicare coding regulations. 
 
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 97530 
is a column II code to column I code 92526. 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 therapeutic activities (97530) provided on April 30, 2021.
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 does 
not meet criteria. 
 
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 you appear to be improving and should only require short-term additional acute care 
services that can be safely administered at the current facility. There are no services at the LTACH that you 
require that are not already available and covered at the current facility. Transfer to a lower level of care may 
be considered when treatment has completed. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on December 3, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that you receive an annual vision check that has not 
been denied in the past. The Plan denied your request. The Plan says the eye refraction is not a covered benefit 
since it was medical vision check (Age-related nuclear cataract, Bilateral). 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. The file shows that you had a medical vision exam for age-related 
nuclear cataracts. Medicare does not pay for procedures performed in the course of any eye exam to determine 
the refractive state of the eyes. Refractive procedures are not covered even when done in connection with 
otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have 
to pay for an eye refraction provided on December 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional routine transportation trips. 
 
You asked the Plan to pre-approve 20 additional trips. You say that the enrollee is unable to drive. You say that 
the enrollee's wife is not able to drive him either. You also say that the requested trips would be for 
transportation to the dermatologist. The Plan denied your request. The Plan says additional routine 
transportation in excess of the allowed 10 one-way trips per year are not covered. 
 
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 Plans coverage rules apply in this case. The Plan covers a maximum of 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 20 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis (Tdap) 
vaccine (90715, 90472) provided on November 1, 2021. 
 
You asked the Plan to pay for the Tdap vaccine. You say that you would like reconsideration because you were 
told that this vaccine would be covered. The Plan denied your request. The Plan says this diagnosis code is not 
considered an appropriate diagnosis for a tetanus vaccine. 
 In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular 
pertussis (Tdap) vaccine (90715, 90472) provided on November 1, 2021.  
 
Benefits for the Tdap vaccine 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
August 4, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim should be paid. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
August 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that that you require 
additional mileage to get to your appointment. The Plan denied your request. The Plan says that your request 
exceeds the benefit limit. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.