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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs and was at a supervision/touch assist level for functional mobility including 
gait to 150 feet. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection (62320) provided on December 6, 2021. 
 
You asked the Plan to pay for the injection. You say that the services should be covered. The Plan denied your 
request. The Plan says the provided documentation does not include date or signatures. 
 
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 injection (62320) provided on December 6, 2021 have been met. Specifically, the file shows that the documentation provided does not include 
a date of service or physician signature. Therefore, we decided that the Plan does not have to pay for the 
injection (62320) provided on December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (J0172). 
 
You asked the Plan to pre-approve Aduhelm. You say that you need the injection as ordered by your physician. 
The Plan denied your request. The Plan says the requested drug is not covered outside of a Medicare-approved 
clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aduhelm. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of Alzheimer's disease with late onset. The record does not indicate that the enrollee is enrolled 
in a coverage with evidence development trial. Therefore, the reviewer found that the elements of the coverage 
criteria are not satisfied and 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm (J0172).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve spine surgery services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says there are network providers 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 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 
spine surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass frames (V2020), trifocal lens (V2303), and anti-
reflective lens coating (V2750), provided on January 26, 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 you have exhausted the Plan's benefit for this item. 
 
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 with up to a $300 allowance for eyewear. 
 
We looked at the file and the Plan's rules. You have exhausted the Plan's benefit for these items and are 
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), and anti-reflective lens coating (V2750), provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 fractions of stereotactic body radiation therapy (SBRT) / image 
guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve radiation therapy services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says that guidelines do not 
support the routine use of the requested type of treatment for your cancer type. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 radiation therapy services. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that for this specific case it appears that the treatment of the nodal metastases is 
disputed. While the American Society for Radiation Oncology (ASTRO) model policy does not specify nodal 
metastases, it is generally accepted safe (when staying within accepted dosimetric constraints) and effective.  
The National Institute of Health sponsored NRG BR001 Phase I study (including patients with breast, lung or 
prostate cancer) included patients with extraosseous abdominal/pelvic sites (including lymph nodes) and 
derived safe dosing guidelines. For this patient, curative intent type treatment would be considered an 
appropriate standard of care in the absence of widespread metastases. 
 
While this is an uncommon clinical situation (limited metastases from a gastrointestinal-junction cancer), and 
the ability to establish medical necessity based on robust data is challenging, SBRT for limited discrete 
metastases is an accepted standard of care. The advantages of SBRT are to allow dose escalation while 
minimizing the volume of normal tissue exposed to high dose radiation. These principles coupled with the 
medically standard application of SBRT to oligometastatic sites would imply that standard medical necessity 
criteria would be met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy services have been met. Therefore, we decided that the Plan 
has to pre-approve 5 fractions of stereotactic body radiation therapy (SBRT) / image guided radiation therapy 
(IGRT).  
 
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 pay for oxygen equipment (E1390) provided November 8, 2021. 
 
You asked the Plan to pay for the oxygen equipment. You say that the oxygen equipment was medically 
necessary. The Plan denied your request. The Plan says this purchase was not pre-authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. 
 
We looked at the file and Medicare rules. This equipment was purchased without pre-authorization and was not 
rented. Based on this information, we decided that Medicare rules for coverage of the oxygen equipment have 
not been met. Therefore, we decided that the Plan does not have to pay for oxygen equipment (E1390) 
provided November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect (0012M) provided November 15, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the service was medically necessary and you 
request that the Plan covers the service. The Plan denied your request. The Plan says CxBladder detect is not 
covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for CxBladder Detect (0012M) provided November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on December 13, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the service. 
 
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 an epidural injection provided on 
December 13, 2021 have been met.  Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on December 13, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on November 24, 2021. 
 
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 that this testing would be unlikely to impact therapeutic decision-making in the clinical 
management of the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is being treated  for acute leukemia not having achieved remission. The review has 
determined the enrollee meets the coverage criteria for this testing. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
laboratory services provided to the enrollee on November 24, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 16, 2021, to January 19, 2021. 
 
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 DRG was updated.  
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 DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the enrollee was admitted and treated in the hospital with COPD exacerbation 
related to pneumonia. He was treated with antibiotics. However, there was insufficient support made in the 
provided documentation that the patient met Sepsis 3 criteria. No GCS scores were documented, no abnormal 
blood gas was documented, platelets, Cr, and bilirubin were each normal. There was no rise in SOFA by 2+ 
points, and the patient had a dry cough with clear chest x-ray. Therefore, the more appropriate DRG for this 
hospital admission is 190 (CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC) based on the 
provided documentation.  
 
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 to the enrollee from January 16, 2021, to January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on 
November 5, 2021. 
 
  You asked the Plan to pay for the moderate sedation services (99152). You say that you are resubmitting the 
claim with medical records to be reviewed for payment. The Plan denied your request. The Plan says procedure 
codes 93456, 93463, 93571 and 93572 have been overturned. The Plan also says CPT code 99152 remains 
denied as the documentation did not support the presence of an independent trained observer. 
 
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 moderate sedation services (99152) 
have been met. Specifically, medical records were not submitted to support sedation services were performed. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided 
on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital management services provided on August 24, 2021. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says only one 
payment will be made per day. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 01996 is 1. The MAI value for this code is 2. You billed more than 1 unit 
of this code, exceeding the MUE. 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 hospital 
management services provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on January 13, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was seen by different specialists. 
The Plan denied your request. The Plan says payment is not allowed. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
 
 We find that CPT code 99292 is not supported. Specifically, the claim was not billed with a primary procedure. 
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 critical care services provided on January 
13, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on October 4, 2021. 
 
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 that this testing is unlikely to impact therapeutic decision-making in the clinical management of 
the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that the enrollee has metastatic sarcoma. FoundationOne Heme is a comprehensive 
genomic profiling (CGP) test combining DNA and RNA sequencing for patients with hematologic 
malignancies, sarcomas or solid tumors where RNA sequencing is desired. The review has determined that the records support that coverage criteria for this testing was met. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
laboratory services provided to the enrollee on October 4, 2021.  
 
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 one hundred (100) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you have upcoming 
appointments with your doctor, and you need additional transportation approved. The Plan denied your request. 
The Plan says you have exhausted your benefit limit for 2022. 
 
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 60 one-way trips per year trips per year.  
 We looked at your request, the records in the case file, and the rules. The records show that you have used 60 
one-way routine transportation trips this year. 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 one hundred (100) additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (62320) provided December 13, 2021. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says insufficient records were provided to support this service. 
 
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 injections (62320) provided December 13, 2021. have been met. Only a procedure note was provided. No office visit notes or clinical documentation 
was provided to show this service was medically necessary. Therefore, we decided that the Plan does not have 
to pay for injections (62320) provided December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you cannot use a hand-crank on a 
semi-electric bed to make adjustments. The Plan denied your request. The Plan says that this is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.