Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) for attenuation correction and anatomical localization imaging (78815). 
 
You asked the Plan to pre-approve a PET scan with a CT scan. You say that you disagree with the denial. The 
Plan denied your request. The Plan says that the request does not meet the Medicare or health plan coverage 
criteria. 
 
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 a CT scan. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the national coverage 
determination enumerates the indications and limitations of coverage for the requested service and states, in 
relevant part, that three FDG PET scans are nationally covered when used to guide subsequent management of 
anti-tumor treatment strategy after completion of initial anti-cancer therapy. In this case, the record indicates 
that the enrollee has a recent history of mucoepidermoid carcinoma of the base of tongue, status post neck 
dissection (2019) and a remote history of Hodgkin lymphoma. The record does not indicate that the enrollee 
has had three scans following completion of initial anti-cancer therapy. The elements of the coverage criteria 
are satisfied. The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan with a CT scan have been met. Therefore, we decided that the Plan 
has to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) for attenuation correction and anatomical localization imaging (78815).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0130). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need more trips in 
order to finish your dialysis treatment. You do not have a car for transportation to dialysis. The Plan denied 
your request. The Plan says you have used 56 trips of your transportation benefit; therefore, you have 
exhausted your benefit limit. 
 
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 50 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 trips (A0130).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open implantation of hypoglossal nerve 
neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array (64582). 
 
You asked the Plan to pre-approve the open implantation. You say that you have horrible sleep apnea and stop 
breathing at night. You also say that the CPAP does not help, and need this service rendered to resolve the 
issue. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that an FDA approved hypoglossal nerve 
neurostimulation is considered medically reasonable and necessary for the treatment of moderate to severe 
obstructive sleep apnea when all of the criteria listed in the Medicare rules section of this letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the open implantation. Our reviewer 
says that you do not meet the criteria for coverage for an open implantation. Our physician reviewer found 
based on the medical records provided, there is no documentation that you meet all of the conditions which are 
indicated for coverage. Our reviewer found that the provided records do not document that you have 
predominantly obstructive events; and apnea-hypopnea index (AHI) is 15 to 65 events per hour; and you have 
documentation that demonstrates continuous positive airway pressure (CPAP) failure or CPAP intolerance 
including shared decision making that you were intolerant of CPAP despite consultation with a sleep expert as 
required by the Local Coverage Determination (LCD) for Hypoglossal Nerve Stimulation for the Treatment of 
Obstructive Sleep Apnea (L38310). Our physician reviewer also found that this is due to the fact that the copy 
of the sleep study provided is indecipherable. 
 
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 open implantation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an open implantation of hypoglossal nerve neurostimulator array, pulse generator, 
and distal respiratory sensor electrode or electrode array (64582).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11981 and J7307 billed for date of service 
April 11, 2022. 
 
You asked the Plan to pay for procedure codes 11981 and J7307. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says code 11981 is not a covered benefit and code is J7307 
invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The rules also say that items/services for 
the purposes of preventing conception (contraception) are not considered medically reasonable and necessary. 
 
Records show that the requested service coded 11981 is primarily for the purpose of contraception. The 
documentation does not show that this service is being requested to treat a specific illness/injury. As such, the 
Medicare rules for coverage of this item/service have not been met. We find that procedure code J7307 has a 
Status Indicator of I on the Physician Fee Schedule. This means that procedure code J7307 is not valid for 
Medicare purposes. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 11981 and J7307 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 11981 and 
J7307 billed for date of service April 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, Paclitaxel, and supporting drugs 
Granisetron, Diphenhydramine, Emend, Dexamethasone, and Famotidine. 
 
You asked the Plan to pre-approve the requested drug regimen. You say that Keytruda is needed to get the 
levels of blood cancer lowered. The Plan denied your request. The Plan says the drugs are not helpful when 
Keytruda did not have a positive response. 
 
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 the requested drug regimen. Our 
physician reviewer found that you have a diagnosis of stage IV non-small cell squamous cell lung cancer. The 
record indicates that you have previously had a progression of disease while on Keytruda. The FDA has not 
stated that the requested drug is indicated for your condition. The Medicare approved cancer drug compendia 
do not contain a supportive citation for the use of the requested drug in your clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are 
not satisfied. The requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested drug regimen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Keytruda, Carboplatin, Paclitaxel, and supporting drugs Granisetron, 
Diphenhydramine, Emend, Dexamethasone, and Famotidine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure code 64636 x 3 units) provided 
to the enrollee on March 11, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the number of units billed. 
 
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, the CPT Code Manual definition of code 64636 is "Destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 
(List separately in addition to code for primary procedure)." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider reported three units 
for destruction by neurolytic agent, each additional facet joint. The procedure report describes treatment at L3, 
L4, L5, S1. In this case, additional units cannot be verified in this case.  
We looked at this coder's review, the file, and Medicare rules. 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 injection services (procedure code 64636 x 3 units) provided to the enrollee on March 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says that the requested epidural steroid injection 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injection. Our 
reviewer says that an epidural steroid injection is medically necessary. Our physician reviewer found that this 
enrollee has post-laminectomy syndrome and an epidural steroid injection is medically reasonable and 
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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for OON care 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 laboratory services provided on March 8, 2022, by 
an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 11, 2021, to 
October 13, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the use of diagnosis code A41.9 is not supported by the records provided. Our physician 
reviewer found that from the information that was received, the documentation was inconsistent/unclear 
regarding a diagnosis of sepsis. Even though sepsis is documented on discharge summary, supporting medical 
record documentation was not found within the record. The enrollee presented with shortness of breath and 
chills. Laboratory results revealed platelet count of 420, creatinine was 0.80, and total bilirubin was 0.4. There 
was no evidence of significant physiologic instability. Although the provider documented sepsis, reasonable 
support within the health record must be present for that diagnosis. There was no clinical or laboratory 
evidence of sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 11, 2021, to October 13, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an outpatient office visit (99203) for an alternative continuous 
positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve an outpatient office visit for an alternative CPAP device. You say that you 
believe it is a matter of life and death that the enrollee receives this treatment. The Plan denied your request. 
The Plan says that the medical notes received do not support the need for this service. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 outpatient office visit for an 
alternative CPAP device. Our reviewer says that an out-of-network consultation to evaluate the enrollee for the 
Inspire device (hypoglossal nerve stimulator) is reasonable and medically necessary. Our physician reviewer 
found this enrollee has moderate obstructive sleep apnea and is unable to manage the CPAP device because of 
a previous stroke and left arm weakness. Our reviewer also found that there is no in-network provider that 
evaluates and treats with the Inspire device. 
 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 outpatient office visit for an alternative CPAP device have been met. 
Therefore, we decided that the Plan has to pre-approve an outpatient office visit (99203) for an alternative 
continuous positive airway pressure (CPAP) device.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear (V5261), 
hearing screening (V5008), assessment for hearing aid (V5010), and conformity evaluation (V5020) provided 
February 25, 2022. 
 
You asked the Plan to pay for the hearing aids, hearing screening, assessment for hearing aids and conformity 
evaluation. You say that these services should be covered. The Plan denied your request. The Plan says the 
documentation does not support that the requested services were performed. 
 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. The documentation does not support that the billed services were 
performed on February 25, 2022. Based on this information, we decided that there is insufficient information in 
the record to determine if Medicare rules for coverage of the hearing aid, digital, binaural, behind the ear 
(V5261), hearing screening (V5008), assessment for hearing aid (V5010), and conformity evaluation (V5020) 
provided February 25, 2022. have been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aid, digital, binaural, behind the ear (V5261), hearing screening (V5008), assessment for hearing aid 
(V5010), and conformity evaluation (V5020) provided February 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you no 
longer have a skilled need. 
 
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 continued services. Our physician 
reviewer found that you no longer qualify for SNF coverage. you do not have documented skilled nursing or 
therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and 
intermittent. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical preparation or creation of recipient site by 
excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children (CPT code 15004) and full thickness graft, free, including 
direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less (15260). 
 
You asked the Plan to pre-approve the services. You say that one nostril is higher up more than the other. The 
Plan denied your request. The Plan says your request is not medically necessary because your records show 
you do not have a functional impairment or documentation of medical necessity for a reconstructive surgery. 
 
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 services. Our physician reviewer 
found the medical record does not indicate that there is functional impairment. The record provided does not 
indicate the presence of a condition for which the procedure would be considered reconstructive, as defined by 
Medicare rules. The medical record provided indicates that the requested procedures are being performed for 
cosmetic purposes. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgical preparation or creation of recipient site by excision of open wounds, burn eschar, 
or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, 
neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and 
children (CPT code 15004) and full thickness graft, free, including direct closure of donor site, nose, ears, 
eyelids, and/or lips; 20 sq cm or less (15260).