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

 
We decided that the Plan does not have to pre-approve inpatient admission. 
 
You asked the Plan to pre-approve inpatient admission. 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 inpatient admission. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee presented to the emergency department with two days of right ear pain. 
The enrollee's vital signs were stable; Laboratory studies revealed white blood cell count of 17 and lactate 2.49. 
The enrollee was started on intravenous antibiotics (Rocephin/Linezolid). The documentation indicates that 
there were no significant acute findings with persistent hemodynamic instability, hypoxia, severe perioperative complications, or acute cardiac event. The enrollee's cultures were negative, the enrollee's mental status 
improved, and the enrollee was tolerating a regular diet. The documentation shows that the enrollee was stable 
and appropriate for observation level of care services. Therefore, the requested services are 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 inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Iron Dextran, Diphenhydramine Hydrochloride (HCL), 
and Hydrocortisone Sodium Succinate. 
 
You asked the Plan to pre-approve Iron Dextran, Diphenhydramine HCL, and Hydrocortisone Sodium 
Succinate. The Plan denied your request. The Plan says this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Iron Dextran, Diphenhydramine HCL, 
and Hydrocortisone Sodium Succinate. Our reviewer says that Iron Dextran, Diphenhydramine HCL, and 
Hydrocortisone Sodium Succinate are not medically reasonable and necessary for you. Our physician reviewer 
found the record indicates that you do not have anemia. The FDA has not stated that the requested drug is 
indicated for your condition. Our reviewer found that the Medicare approved drug compendia do not contain a 
supportive citation for the use of the requested drug in your clinical situation. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Iron Dextran, Diphenhydramine HCL, and Hydrocortisone Sodium Succinate 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Iron Dextran, 
Diphenhydramine Hydrochloride (HCL), and Hydrocortisone Sodium Succinate.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (code 99283) provided on 
December 27, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services rendered were 
emergency services that were medically necessary. The Plan denied your request. The Plan says the claim 
denied due to needing a Medicare ID number, as well as a Medicare Certification Letter, for processing and 
payment. Upon review it was determined that this provider is a non-Medicare approved/certified 
freestanding emergency facility. This facility is not a hospital and has no affiliation with a hospital. 
 
The Plan must follow Medicare rules. Medicare says that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. We looked at the file and Medicare rules. The file shows that this facility is not a hospital and has no affiliation 
with a hospital. Based on this information, we decided that Medicare rules for coverage of the emergency 
department visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency 
department visit (code 99283) provided on December 27, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an attended follow up sleep study (95810). 
 
You asked the Plan to pre-approve an attended follow up sleep study. The Plan denied your request. The Plan 
says that the records show you have an established sleep apnea diagnosis with use of CPAP. The Plan also says 
there are no documented changes in your condition which would warrant a new sleep study prior to obtaining a 
new CPAP machine. 
 
The Plan follows Medicare rules. Medicare rules say that a follow-up PSG may be indicated under the 
circumstances listed in the Medicare rules section of this letter. 
 
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 an attended follow up sleep study. Our 
reviewer says that a diagnostic polysomnography (PSG) is considered reasonable and medically necessary. Our 
physician reviewer found you have a past history of obstructive sleep apnea (OSA), treated with CPAP. You 
wore the CPAP for only a short time because of intolerance. Our reviewer found that you had bariatric surgery 
in 2021 and lost 70 pounds. Currently the Epworth score is increased at 11. Our physician reviewer found that 
given the substantial weight loss, it is reasonable to repeat the PSG to see if you still have OSA. Our reviewer 
also found that very severe obesity necessitates an attended PSG. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended follow up sleep study have been met. Therefore, we decided that the 
Plan has to pre-approve an attended follow up sleep study (95810).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
November 4, 2022, billed with code 99285. 
 
You asked the Plan to pay for the ED services. You say that multiple exams were done on the same date of 
service. The Plan denied your request. The Plan says this claim is duplicate to a previously paid claim. 
 
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 ED services have been met. 
Though the claim is not an exact duplicate of a previous claim, the file shows that payment was made for code 
99285 to the same physician on January 6, 2023. There is no evidence presented to support that the provider 
rendered two separate emergency department consultations to the enrollee on this date of service. As such, we 
find that the denial of this claim is supported. Therefore, we decided that the Plan does not have to pay for the 
emergency department (ED) services provided on November 4, 2022, billed with code 99285.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Cogenex amniotic membrane (Q4229). 
 
You asked the Plan to pre-approve Cogenex amniotic membrane. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 Cogenex amniotic membrane. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is insufficient evidence in the medical literature regarding the use of 
Cogenex amniotic membrane in the setting of nonhealing surgical and radiation wounds. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cogenex amniotic membrane have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the use of Cogenex amniotic membrane (Q4229).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that the chronic illnesses are illnesses of long 
duration and generally slow progression. You also say that you feel you are an object of unfair treatment and 
unjustified, since even though of knowing of your conditions of health, you were not evaluated on a correct 
manner. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).  
 
Your complaint about feeling you are an object of unfair treatment is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multilevel fusion. 
 
You asked the Plan to pre-approve multilevel fusion. 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 multilevel fusion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for radiculopathy of the lumbar region. The enrollee 
presented with low back and bilateral lower extremity pain. There is numbness in the tailbone and the bilateral 
lower extremities radiating to the feet with burning in the bilateral thighs. The symptoms have been present 
intermittently for years and progressively worsened in December 2022. The enrollee is a 1 pack per day smoker. The exam reveals decreased lower extremity strength with bilateral hip flexion at four out of five and 
bilateral quadriceps at four plus out of five. There is numbness in the tailbone and the bilateral lower 
extremities. However, detailed documentation is not evident regarding smoking cessation as the enrollee was 
noted on the April 18, 2023, pre-operative exam to be smoking half pack per day. Moreover, dynamic 
flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at 
the requested surgical level. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. 
 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. No compelling rationale is presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 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 multilevel fusion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve multilevel fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4239 billed for date of service January 4, 2023. 
 
You asked the Plan to pay for code A4239. The Plan denied your request. The Plan says code A4239 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 code A4239 has a status indicator of P on the Physician Fee Schedule. This means that code 
A4239 is not separately payable. Based on this information, we decided that Medicare rules for coverage of code A4239 have not been met. Therefore, we decided that the Plan does not have to pay for code A4239 billed 
for date of service January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided superficial radiotherapy (IGSRT) 
services. 
 
You asked the Plan to pre-approve IGSRT services. You say that the requested treatment is medically 
necessary. The Plan denied your request. The Plan says there is not enough medical evidence to show that this 
type of radiation treatment is effective to treat the enrollee's skin cancer. 
 
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 IGSRT services. Our reviewer says that 
IGSRT services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is 
approved by the Food and Drug Administration (FDA) for use with ultrasound. However, that in and of itself does not mean that daily imaging is necessary but simply that the device was designed to incorporate this 
functionality. Therefore, to bill for daily simple simulations and/or IGSRT for a technology for which need has 
not been established by published data or supported by consensus guidelines (many of which recommend 
against treatment with these devices in general) is not 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 IGSRT services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve image-guided superficial radiotherapy (IGSRT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit provided on 
October 20, 2022. 
 
You asked the Plan to pay for the office or other outpatient visit. The Plan denied your request. The Plan says 
that the Plan requires utilization of network providers when possible and available and requires authorization 
for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent 
situation that has been documented.   
 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office or other outpatient visit provided on October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on December 13, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test provided on December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 7, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. 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 hyperbaric oxygen therapy 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 hyperbaric oxygen therapy. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee awoke with acute monocular vision loss. The enrollee 
had a central retinal artery occlusion and was treated with twice daily hyperbaric oxygen therapy with marginal 
improvement in your visual acuity. The enrollee still was unable to read any lines on the Snellen chart. The 
enrollee was discharged on April 25th, 2023, noting that the enrollees progress had stagnated. The 
documentation indicates that while hyperbaric oxygen therapy may have been appropriate acutely, the 
enrollee's visual status has now plateaued. A meta-analysis of hyperbaric oxygen therapy for central retinal 
artery occlusion showed that the median number of sessions was three. 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 hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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 services are not medically necessary. Our physician reviewer found the records are lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. The documentation does not 
support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary 
and/or reasonable at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme test provided on November 9, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the FoundationOne Heme test. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says there was no medical necessity for using an OON 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 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 the FoundationOne Heme test provided on 
November 9, 2022, by an out-of-network (OON) provider.