Persius/hicric huggingface dataset:
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 criteria for coverage for Injectafer. Our physician reviewer found based on the 
medical records provided there is no indication that the enrollee has tried and failed the required drug. Our 
reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or 
likely have adverse effects for the enrollee. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that HBO therapy is medically necessary. The Plan 
denied your request. The Plan says the patient does not meet criteria for hyperbaric oxygen therapy. The 
records do not show that the patient has optimal blood flow and infected tissue has been removed (debrided) adequately. Neither do they show the patient has adequately been treated by antibiotics for the skin and bone 
infection. 
 
The Plan follows Medicare rules. Medicare rules say that HBO therapy is coverable for patients with diabetic 
ulcers only when an assessment of the patient's vascular status and correction of any vascular problems have 
occurred. 
 
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 HBO therapy. Our reviewer says that 
the patient does not meet criteria for HBO therapy. Our physician reviewer found the enrollee is a 94 year-old 
female with a Wagner grade 3 diabetic foot ulcer that has failed standard wound care. She has been treated with 
wound care since January. Although you are requesting approval of HBO for limb salvage and to prevent 
amputation, the patient has not had optimal treatment of her peripheral vascular disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that the medical records show this service is not 
bundled. The Plan denied your request. The Plan says there are no circumstances in which both procedures of 
the code pair should be paid for the same beneficiary on the same day. 
  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 99232 
is a column II code to column I code 99233 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99232 billed for date of service May 23, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for drug testing. We decided that the Plan does not have to pay for validity 
testing.  
 
You asked the Plan to pay for drug testing (80307) and specimen validity testing (83789) billed for date of 
service June 7, 2022.. You say that the services at issue were billed correctly. The Plan says that rules for 
payment have not been met. 
 
We decided that the Plan has to pay for drug testing.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plans denial states that a prior instance of drug testing coded in 
the range 80305 to 80307 was reported for the same date of service. The case record does not contain 
documentation of a prior report of such a code for the same date of service. The Plan has not provided any 
other denial rationale for drug testing coded 80307. It is the Plans responsibility to substantiate its denial with 
evidence. In this case, the Plans denial has not been substantiated, so we must find in your favor. Therefore, 
we decided that the Plan has to pay for drug testing (80307).  
 
We also decided that the Plan does not have to pay for validity testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) for the enrollee. 
 
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan 
denied your request. The Plan says the records state that the enrollee takes insulin on a fixed dose. There is no 
adjusting and no sliding scale.  
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic covered when all the criteria listed 
are met. Based on the medical records provided, Medicare rules for coverage of this device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) for the 
enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission to be provided 
by an out-of-network (OON) facility. 
 
You asked the Plan to pre-approve OON SNF admission. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says OON SNF admission is not covered as there are 
network facilities available. 
 
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 facility in this case is not a network facility with the Plan. The Plan has network facilities 
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 
skilled nursing facility (SNF) admission to be provided by an out-of-network (OON) facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation (D0150) for a root canal with a 
specialist. 
 
You asked the Plan to pre-approve the consultation (D0150). You say that you have an abscess close to your 
sinus cavity. You say if you do not get it taken care of quickly, then it could be life threatening. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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 consultation (D0150) is not among 
those covered under this benefit. Specifically, the service must be performed by a participating general dentist. 
Therefore, we decided that the Plan does not have to pre-approve the consultation (D0150) for a root canal with 
a specialist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures in a fire. You say 
you only have four teeth and need your dentures replaced. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 21, 2022. Therefore, 
we decided that the Plan does not have to pre-approve the lower partial denture (D5214).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan with Computed 
Tomography (CT) for attenuation. 
 
You asked the Plan to pre-approve a PET scan with CT for attenuation. You say that a PET scan with CT for 
attenuation is medically necessary. The Plan denied your request. The Plan says that a PET scan with CT for 
attenuation is 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 a PET scan with CT for attenuation. 
Our reviewer says that a PET scan with CT for attenuation is medically necessary. Our physician reviewer 
found that fluorine-18-fluorodeoxyglucose-positron emission tomography (FDG-PET) is sometimes helpful to 
identify occult lesions that are more accessible to biopsy than lung lesions, as well as in the evaluation of 
cardiac sarcoidosis. FDG-PET has largely replaced older imaging methods, such as Gallium scintigraphy 
and Thallium or Technicium SPECT, due to greater sensitivity. It is now the standard of care for the work-up 
of pulmonary sarcoidosis. The service is reasonable and 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 a PET scan with CT for attenuation have been met. Therefore, we decided that 
the Plan has to pre-approve a PET scan with CT for attenuation.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a black egg switch and rod and egg switch mouth. 
 
You asked the Plan to pre-approve a black egg switch and rod and egg switch mouth. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications.  
 
 
 
 
 We looked at the file and Medicare rules. These requested items are already included with the approved 
expandable controller. This means these requested items cannot be separately requested. Based on this 
information, we decided that Medicare rules for coverage of a black egg switch and rod and egg switch mouth 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a black egg switch and 
rod and egg switch mouth.
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 demonstrates functional decline and 
ability to tolerate intensive rehab. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate 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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120). 
 
You asked the Plan to pre-approve an evaluation. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says dental services from an out-of-network provider are not covered 
by your supplemental benefits. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a periodic 
oral evaluation (D0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87641, 87581, 87486, 87631, 87653, 87798, 87541, 
87532, 87498, and 87496 provided on January 5, 2022. 
 
You asked the Plan to pay for codes 87641, 87581, 87486, 87631, 87653, 87798, 87541, 87532, 87498, and 
87496. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services billed are not supported by the documentation. 
 
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 87641, 87581, 87486, 87631, 87653, 87798, 87541, 87532, 87498, and 87496 are not 
supported in the medical record. Specifically, the documentation did not include an order for these services. 
Based on this information, we decided that Medicare rules for coverage of codes 87641, 87581, 87486, 87631, 
87653, 87798, 87541, 87532, 87498, and 87496 have not been met. Therefore, we decided that the Plan does 
not have to pay for codes 87641, 87581, 87486, 87631, 87653, 87798, 87541, 87532, 87498, and 87496 
provided on January 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance image (MRI) of the ankle. 
 
You asked the Plan to pre-approve the MRI. You say that this MRI is needed because your foot is swollen and 
your doctor suspects there is more to your condition regarding your foot. The Plan denied your request. The 
Plan says the requested MRI (code 73721- MRI, any joint of lower extremity) is not medically necessary 
because an MRI of the foot (code 73718- MRI, lower extremity other than joint) has already been approved. 
An MRI of the foot should include the posterior foot and ankle joint. Repeating the MRI of the ankle is 
duplicative and not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that an 
MRI of the foot is not medically necessary. Our physician reviewer found the plan has approved MRI of the 
right foot, (code 73718) and MRI of the symptomatic right foot is appropriate.  There is no note or explanation 
as to the reason MRI of the right ankle, (code 73721) is also necessary.  The approved 73718 denotes MRI of 
the lower extremity and should cover the entire right foot, the area of clinical concern. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance image (MRI) of the ankle.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to treat temporomandibular joint (TMJ) 
syndrome. 
 
You asked the Plan to pre-approve this treatment. You say that this treatment is medically necessary. The Plan 
denied your request. The Plan says this treatment is not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature or is the result of a separate medical condition. Based on 
the medical records provided, those criteria are not met. Therefore, we decided that the Plan does not have to 
pre-approve dental services to treat temporomandibular joint (TMJ) syndrome.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LINX procedure. 
 
You asked the Plan to pre-approve LINX procedure. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve LINX procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee documents has uncomplicated gastroesophageal reflux disease (GERD) 
without Barrett's esophagus or dysphagia. The enrollee's provided composite DeMeester score of 13.5 was 
normal, no hiatal hernia was identified by manometry, and lower esophageal sphincter tone and function was 
documented as normal. The documentation notes significant symptom benefit from proton pump inhibitor use. 
Diabetic gastroparesis has however not been ruled out as a contributor to residual symptoms that the enrollee 
attributes to GERD. Available records support opportunity for improvement in the enrollees lifestyle to 
optimize reflux control. 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 LINX procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LINX procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has no longer been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require daily skilled nursing or therapy services. The physician 
reviewer also found that you do not meet the severity of illness or intensity of service criteria for an inpatient 
basis in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care.