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

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from 
February 13, 2023, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee is having suicidal 
thoughts and is not safe to be discharged. The Plan denied your request. The Plan says the stay is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this enrollee does not 
meet the criteria for February 13, 2023, forward as this enrollee was not shown to be a danger to the enrollee or 
others, delusions, auditory or visual hallucinations noted. The enrollee was cooperative/compliant with 
treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from February 13, 2023, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve add tooth to existing partial denture (D5650). 
 
You asked the Plan to pre-approve the dental services. You say that your partial doesn't fit correctly and one 
tooth keeps breaking off. You also say that you have been back for the same issue and feel the dental facility 
should pay the charges. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. You already 
received replace broken teeth - per tooth code D5640 which shares the frequency with dental code D5650. The 
record shows your benefit for the D5650 was exhausted on date of service January 11, 2022. Therefore, we 
decided that the Plan does not have to pre-approve add tooth to existing partial denture D5650.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services provided on September 28, 2022, 
billed with code 75716-59. 
 
You asked the Plan to pay for the angiography services. You say that this code should be paid. The Plan denied 
your request. The Plan says modifier -59 is not supported for use with code 75716. 
 
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 75716 is a column II code to column I code 37221; however, 75716 
was billed with a modifier.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the angiography services have not been met. Specifically, the documentation does not provide any 
indication that angiograms were provided that were not directly related to the overall procedure performed. As 
such, the use of modifier -59 to bypass the edit is not supported. Therefore, we decided that the Plan does not 
have to pay for the angiography services provided on September 28, 2022, billed with code 75716-59.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet 
joint. 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint. 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 follows Medicare rules. Medicare rules say that destruction by neurolytic agent, paravertebral facet 
joint is only covered for certain indications. 
 
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 destruction by neurolytic agent, 
paravertebral facet joint. Our reviewer says that the documentation does not support that the requested services 
are medically reasonable or necessary. Our physician reviewer found the enrollee has had the requested 
procedure performed at the L5-S1 level. The record provided does not document the performance of the 
requested procedure previously at the requested L4-L5 level or the performance of diagnostic blocks as 
required by the coverage rules. 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 destruction by neurolytic agent, paravertebral facet joint have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral 
facet joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC) described by code K0898. 
 
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 a PMD 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 records show that you had not 
received an evaluation from an appropriately-certified professional when the PMD was requested. The criteria 
for coverage are not met and the PMD is not 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 a power wheelchair (PWC) described by code K0898.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s) 
is helpful for treatment of the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research 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 the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital admission. 
 
You asked the Plan to pre-approve inpatient hospital admission. You say that the requested inpatient hospital 
admission is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital 
admission 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 inpatient hospital admission. Our 
reviewer says that the requested inpatient hospital admission is not medically necessary. Our physician 
reviewer found the enrollee was being treated for osteoarthritis of the left shoulder. She presented with her left-
hand numbness. This has been constant for the past few months. She is scheduled for left total shoulder 
replacement in 3 weeks. The exam did not provide any shoulder findings. The requested total shoulder 
arthroplasty is documented to have been supported by the Plan. However, detailed documentation is not evident 
regarding a significant past and/or current medical history that would place this enrollee at increased risk for 
peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital admission have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of Keytruda (J9271) after disease 
progression. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee has limited treatment options due to 
extremely poor prognosis. You say that treatment should be continued until disease progression has been 
confirmed. You also say that the requested treatment is medically necessary for the enrollee. The Plan denied 
your request. The Plan says the request 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 Keytruda. Our reviewer says that the 
requested use of Keytruda is not medically necessary. Our physician reviewer found the record indicates that 
the enrollee has had disease progression while receiving the requested treatment. The Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested use of Keytruda 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued use of Keytruda (J9271) after disease progression.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature represented by code 
E2300. 
 
You asked the Plan to pre-approve code E2300. You say that the records provided support the need for a power 
seat elevation feature. The Plan denied your request. The Plan says the item which remains in dispute is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E2300 have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power seat elevation feature represented by code E2300.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has medical needs that require daily 
physician oversight and meet the requirements of Medicare guidelines to receive the requested services. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
IRF. The enrollee's needs can be met at a lower level of care such as 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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this service was medically necessary. The Plan denied your request. The Plan says procedure code 36000 is considered bundled and not separately payable.
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service July 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolin. 
 
You asked the Plan to pre-approve Novolin. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical 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 Novolin.  
 
Benefits for Novolin 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home infusion therapy and pain pump described by 
codes S9328 and 99601. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. The requested services are home infusion therapy. 
Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the home infusion therapy and 
pain pump described by codes S9328 and 99601.  
 
Benefits for these services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on April 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Biodesix Blood based Veristat Proteomic test (81404, 
81479, 81401). 
 
You asked the Plan to pre-approve Biodesix Blood based Veristat Proteomic test. 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 follows Medicare rules. Medicare rules say that NGS is covered under certain conditions. 
 
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 Biodesix Blood based Veristat 
Proteomic test. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
under Medicare guidelines, your request is not medically necessary because your records show that you do not 
have recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Biodesix Blood based Veristat Proteomic test have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Biodesix Blood based Veristat Proteomic test (81404, 
81479, 81401).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 14, 
2022. 
 
You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99223. 
 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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service August 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on September 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services (G0482) provided on September 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet the coverage criteria for Injectafer. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.