Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, below knee, acrylic 
socket (L5629), an addition to lower extremity, below knee, flexible inner socket (L5645), an addition to lower 
extremity, below knee, total contact (L5637), an addition to lower extremity, below knee, suction socket 
(L5647), an addition to lower extremity, below knee/above knee, custom fabricated from existing mold or 
prefabricated, socket insert, silicone gel (L5679), an addition to lower extremity prosthesis, below knee, 
suspension/sealing sleeve, with or without valve, any material (L5685), an addition, endoskeletal system, 
below knee, alignable system (L5910), an addition, endoskeletal system, below knee, ultra-light material 
(L5940), a prosthetic sock, single ply (L8470) and a prosthetic sock, multiple ply (L8420) to be provided by an 
out-of-network (OON) provider.  
You asked the Plan to pre-approve the requested prosthetics. You say that the enrollee is requesting to have a 
prosthesis below his right knee. He had his right leg amputated below his knee due to diabetes, his current 
prosthesis fits too tight and causes pain and discomfort. This causes problems with his residual limbs, as he is 
very active, riding his bike, walking around flea markets. He needs a prosthesis that will enable him to be 
active and not have issues such as pain and discomfort. The Plan denied your request. The Plan says there are 
in-network therapy providers who are available to provide the requested prosthetic services within a reasonable 
distance from the enrollee's location. 
 
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 addition to lower extremity, below knee, acrylic socket (L5629), an addition to lower extremity, below knee, 
flexible inner socket (L5645), an addition to lower extremity, below knee, total contact (L5637), an addition to 
lower extremity, below knee, suction socket (L5647), an addition to lower extremity, below knee/above knee, 
custom fabricated from existing mold or prefabricated, socket insert, silicone gel (L5679), an addition to lower 
extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material (L5685), an 
addition, endoskeletal system, below knee, alignable system (L5910), an addition, endoskeletal system, below 
knee, ultra-light material (L5940), a prosthetic sock, single ply (L8470) and a prosthetic sock, multiple ply 
(L8420) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member will not benefit significantly from skilled therapy of at 
least 3 hours a day 15 hours a week. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pulmonary 
embolism. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on July 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made. 
 
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 codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT code 99100 and 99140 is not separately payable. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the anesthesia services provided on July 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says 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 the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found as a practical matter, 
you would not require daily skilled nursing or therapy services on in an inpatient basis in a skilled nursing 
facility. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88305) provided on May 25, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
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 laboratory 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 laboratory services (88305) provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided on December 12, 2021. 
 
You asked the Plan to pay for IRF care. You say that you were given less than 24 hours that the enrollee's 
coverage would run out. You say that due to the coronavirus, they were not able to find a bed in a skilled 
nursing facility before the enrollee's coverage ran out. The Plan denied your request. The Plan says the needs 
could be provided at a lower level of care. 
 
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 pay for 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 the provided documentation does not indicate that the enrollee had complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. Therefore, the reviewer found that the IRF 
care was 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for acute inpatient rehabilitation facility (IRF) admission and services provided on December 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick injector pen. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has had a positive 
response while on this drug. The Plan denied your request. The Plan says the denial of authorization for this 
drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the 
enrollee's Medicare Part D prescription drug benefits. 
 
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 Repatha SureClick injector 
pen.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the knee provided on June 18, 2021, by an out-
of-network (OON) provider of mobile X-ray services. 
 
You asked the Plan to pay for an X-ray of the knee. You say that regular Medicare allows payment for mobile 
X-rays. The Plan denied your request. The Plan says rules for payment for out-of-network services have not 
been met. 
 
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 of the knee provided on June 18, 2021, 
by an out-of-network (OON) provider of mobile X-ray services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 27, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says payment is 
combined with the payment for services which they are incident. 
 
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 99051 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99051 is not separately payable. 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 
medical services provided on November 27, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on October 31, 
2021. 
 
You asked the Plan to pay for an emergency room visit. You say that this was billed with an appropriate 
diagnosis code. The Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that some International Classification of Diseases, 
10th Revision, Clinical Modification (ICD-10-CM) codes indicate laterality, specifying whether the condition 
occurs on the left, right or is bilateral. If the side is not identified in the medical record, assign the code for the 
unspecified side. 
 
We looked at the file and Medicare rules. The service at issue was billed with diagnosis code M79.669, pain in 
unspecified lower leg, but the records identify that the pain occurred in the left leg. The billing of an 
unspecified side is not appropriate when the laterality is identified in the records. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided 
that the Plan does not have to pay for an emergency room visit (99285) provided on October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass frames (V2020), trifocal lens (V2303, V2304), 
and anti-reflective lens coating (V2750), provide don January 20, 2022. 
 
You asked the Plan to pay for the eyewear. You say that the items should be covered. The Plan denied your 
request. The Plan says the maximum allowance for this benefit has been exhausted. 
 
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 covers these services up to $150 every 24 months. 
 
We looked at the file and the Plan's rules. The cost of the eyewear has exceeded the allowed $150 making you 
responsible for the difference. Based on this information, we decided that the Plan's rules for coverage of the 
eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass frames 
(V2020), trifocal lens (V2303, V2304), and anti-reflective lens coating (V2750), provide don January 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (procedure codes 96116, 
96121, 96132, 96133 x 5 units, 96136, and 96137 x 7 units). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that the requested services are required 
to determine the enrollee's treatment plan. 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 neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation does not indicate that the 
enrollee is showing severity of symptoms that would warrant the type of diagnostic treatment being requested.  
Therefore, the reviewer found that the requested testing does not appear medically necessary or reasonable. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (procedure codes 96116, 96121, 96132, 96133 x 
5 units, 96136, and 96137 x 7 units).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the chest (71260). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the record shows the enrollee's fevers are 
normalizing. Records do not support that this imaging is 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 the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) of the chest (71260).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carboplatin, cetuximab, and paclitaxel. 
 
You asked the Plan to pre-approve carboplatin, cetuximab, and paclitaxel. You say that the records provided 
support the need for the requested drugs. The Plan denied your request. The Plan says the requested drugs are 
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 carboplatin, cetuximab, and paclitaxel. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the requested 
regimen of drugs are not FDA-approved for the enrollee's diagnosis. The use of this regimen is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
Other regimens are preferred, even in elderly or frail patients, per NCCN guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of carboplatin, cetuximab, and paclitaxel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve carboplatin, cetuximab, and paclitaxel.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel rendered on August 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular pathology 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee received the Tempus gene 
panel for a diagnosis of invasive ductal carcinoma. The documentation contains no stage of the cancer, history 
and exam, or plan for use for the test results. The National Comprehensive Cancer Network (NCCN) guidelines 
state that testing is appropriate for invasive breast cancer based on invasive disease and new diagnosis; 
however, the testing is only allowed once and has already had prior approval. The criteria for coverage are not 
met and the testing was 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 pay for the genetic testing panel rendered on August 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manipulation under anesthesia (24300) of the left elbow 
for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is not enough medical proof that shows the safety and/or 
success of manipulation under anesthesia for left elbow stiffness. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures. There is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the enrollee's pathology. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve manipulation under anesthesia (24300) of the left elbow for the enrollee.