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

 
We decided that the Plan does not have to pre-approve treatment with Pegfilgrastim (J2506). 
 
You asked the Plan to pre-approve Pegfilgrastim. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested drug have 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 Pegfilgrastim. Our reviewer says that 
the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has a diagnosis of stage IV colon cancer. The enrollee is receiving a chemotherapeutic regimen 
that is not associated with a clinically significant incidence of febrile neutropenia. The 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. No 
literature from Medicare-approved cancer journals was 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 Pegfilgrastim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Pegfilgrastim (J2506).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided on December 17, 2021. 
 
You asked the Plan to pay for the testing services. You say that the evidence supports the use as medically 
necessary. The Plan denied your request. The Plan says the clinical value has not been demonstrated. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. In this case, there are insufficient medical records to show the enrollees 
treating physician ordered the testing for a specific diagnosis or treatment strategy. The records provided show 
the tests facilitates early detection of bladder cancer. Medicare does not cover this test solely for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the CxBladder test provided on 
December 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on 
January 25, 2022. 
 You asked the Plan to pay for the computed tomography (CT). You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 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 the computed tomography (CT) coded 70450 provided on 
January 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to get 
to your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 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 additional routine transportation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF)services. 
 
You asked the Plan to pre-approve SNF services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee did not meet the Medicare criteria for coverage. 
 
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 services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found the enrollee does not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF)services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97014 billed for date of service October 6, 
2021. 
 
You asked the Plan to pay for procedure code 97014. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this procedure code is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97014 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97014 billed for date of service October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home test kit provided on January 21, 2022. 
 
You asked the Plan to pay for the COVID-19 home test kit. You say that you would to be reimbursed for the 
COVID-19 test kit. The Plan denied your request. The Plan says this claim denied correctly and no payment is 
able to be made for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare did not provide coverage for at-home 
COVID-19 self-tests on the date of purchase. Therefore, we decided that the Plan does not have to pay for the 
COVID-19 home test kit provided on January 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that the enrollee 
needs to get to medical appointments. The Plan denied your request. The Plan says your benefit only allows 60 
one-way trips with each one-way trip not exceeding 75 miles of driving distance. 
 
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 routine transportation when the driving distance for a one-way trip is within 75 miles.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 86.4 miles away from the enrollees residence. The Plan only covers distances up to 75 miles. 
Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips once your benefit runs 
out. 
 
You asked the Plan to provide additional transportation. You say that you need more transportation to continue 
to get to your appointments. The Plan denied your request. The Plan says your benefit covers up to 100 trips 
per year. Additional trips are not a covered benefit. 
 
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 100 trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to provide additional routine transportation trips once your benefit runs out.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
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 PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has prostate cancer and the 
PET scan is being requested to determine initial treatment strategy. This indication is excluded from coverage. 
The PET scan is therefore 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 a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate specific antigen test provided on February 7, 
2022. 
 
You asked the Plan to pay for the prostate specific antigen test. You say that you would like this claim 
reprocessed and approved for payment based on Medicare criteria. The Plan denied your request. The Plan says 
a corrected claim with an appropriate diagnosis has not been received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the prostate specific antigen test 
provided on February 7, 2022, have been met. In this case, no medical records were received despite multiple 
attempts by the Plan. Without medical records, the services billed cannot be corroborated as required for 
payment.  Therefore, we decided that the Plan does not have to pay for the prostate specific antigen test 
provided on February 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the lower 
extremity (73700). 
 
You asked the Plan to pre-approve CT scan services. You say that the requested CT scan is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CT scan services. Our reviewer says 
that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the 
patient is an 83-year-old female with osteoarthritis of the left knee who failed conservative treatments, steroid 
injections. Preoperative CT scan for a robotic left total knee arthroplasty procedure. The provided 
documentation did show abnormal x-rays of the left knee or surrounding area to support follow up with 
advanced imaging (CT) in this clinical setting preoperatively. Insufficient evidence exists to support routine CT 
scan services preoperatively prior to knee arthroplasty, particularly robot-assisted. Therefore, this request for 
such will be considered not medically necessary 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 CT scan services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the computed tomography (CT) scan of the lower extremity (73700).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) and advanced care planning 
(99497) provided on February 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for initial observation care and advanced care planning. You say that you are 
hospital based and your providers rely on the facility to obtain proper authorization. The Plan denied your 
request. The Plan says services were provided by an out-of-network provider without prior authorization. 
 
 
 
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 initial observation care (99220) and advanced care 
planning (99497) provided on February 12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (85060) provided on February 1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable 
for this place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 
 
 
 
 We find that payment CPT code 85060 is not supported in the medical record. Specifically, code 85060 is 
assigned a PC/TC indicator of 8. This means that payment for this code cannot be made for hospital outpatients 
or non-hospital patients. This code was billed with an outpatient hospital place of service. 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 the lab services (85060) provided on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued inpatient psychiatric services. You say that the clinical 
information provided supports the need for the requested inpatient care. The Plan denied your request. The Plan 
says the guidelines for coverage have not been met. 
 
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 continued inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
was admitted to the acute inpatient psychiatric hospitalization on June 14, 2022, with Unspecified Psychosis 
Not Due to Substance, Reaction to Severe Stress and Disruptive Mood Dysregulation Disorder. Based upon 
review the records provided it was not expected this enrollee would improve in a reasonable period of time for 
the dates in question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. The 
patient was compliant with treatment while not showing any acute threats to safety. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question as she did not have dangerousness to self or others and was 
compliant with her treatment. It did not appear that the services were reasonably expected to improve the 
patients condition or for the purpose of diagnosis beyond the date in question. She 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 continued inpatient psychiatric services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a specialist (99214) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are requesting approval for a follow-up 
office visit with the enrollee. The Plan denied your request. The Plan says the records do not discuss 
circumstances that cannot be controlled by a provider in your individual network or that your primary care 
provider has stated that you require the services of this provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with a specialist (99214) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Next Generation Sequencing (NGS) genetic testing. 
 
You asked the Plan to pre-approve NGS genetic testing. You say that the requested testing is important because 
you have surgery in two weeks, and it will help to determine how to proceed. You say that you were adopted 
and are unaware of your family history. You say that you need to know whether you carry the gene. The Plan 
denied your request. The Plan says the requested testing is not considered medically necessary in this case. 
 
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 NGS genetic testing. Our reviewer says 
that NGS genetic testing is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of grade 1 adenocarcinoma of the left breast and an unknown family 
history. Based on the documentation in the case file, it cannot be determined that the enrollee has a clinical 
indication for germline (inherited) testing for hereditary breast or ovarian cancer, and a risk factor for germline 
(inherited) breast or ovarian 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 NGS genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Next Generation Sequencing (NGS) genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve out-of-network hearing aids. You say that hearing aids are necessary. The 
Plan denied your request. The Plan says the provider requested in this case is not part of the Plan's network. 
There are in-network providers who would be able to provide the necessary care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
hearing aids to be provided by an out-of-network (OON) provider.