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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
You asked the Plan to pre-approve SNF care. You say that the enrollee has not reached maximum function and 
requires more time. The Plan denied your request. The Plan says the enrollee no longer requires skilled therapy 
or nursing services on a daily inpatient basis. 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 the enrollee has no identifiable skilled therapy or skilled nursing service needs. The 
enrollee does not meet the 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services were reported correctly. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 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 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Gamunex-C immune globulin. 
 
You asked the Plan to pre-approve Gamunex-C. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says studies have not proven that this is safe and effective for the enrollee's 
condition. 
 
The Plan follows Medicare rules. Medicare rules state that immune globulin may be covered for FDA-label 
indications or for certain other specified 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 Gamunex-C. Our reviewer says that the 
enrollee does not meet criteria for Gamunex-C. Our physician reviewer found the Food & Drug Administration 
(FDA) has not stated that the requested drug is indicated for the enrollee's condition. The noted condition is not 
listed by Medicare rules as one for which coverage of the drug is available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of Gamunex-C immune globulin.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both Alzheimer's disease (AD) and Frontotemporal disorders (FTD). 
 
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 of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case the records 
provided only suggested the presence of AD and possibly chronic ischemic changes as a cause for the enrollee's 
cognitive complaints. This is in contrast to the requirements of the NCD which limit the provision of the 
requested service to enrollees who meet diagnostic criteria for both AD and FTD. As the enrollee does not meet 
diagnostic criteria for FTD, this service cannot be said to be reasonable and necessary for the enrollee at this 
time. Nor would it meet the base requirement for coverage as defined by the NCD. 
 
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 of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Opdivo and Yervoy. 
 
You asked the Plan to pre-approve Opdivo and Yervoy. You say that the enrollee needs to undergo 
chemotherapy as soon as possible. The Plan denied your request. The Plan says studies have not proven that 
these drugs are helpful when the enrollee tried - but did not have a positive response to - another anti-PD1 drug. 
 
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 Opdivo and Yervoy. Our reviewer says 
that the enrollee does not meet criteria for the requested drug combination. Our physician reviewer found 
Opdivo and Yervoy are not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. There 
was progression on prior PDL-1 therapy. This use is not supported by one of the major drug compendia or by 
clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo and Yervoy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of Opdivo and Yervoy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and humidifier. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you do 
not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that positive airway pressure devices are only covered 
under certain medical 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 the requested device. Our physician 
reviewer found that you have a diagnosis of obstructive sleep apnea established in 2010 and have been on 
CPAP in the past. Currently your device is not working, and you are not using it regularly. You have excessive 
daytime sleepiness, headaches, and frequent arousals. A sleep study on February 1, 2023, showed a normal 
AHI, but frequent arousals, consistent with mild upper airways resistance syndrome. This does not meet 
Medicare criteria for sleep apnea. Therefore, the request is 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous positive airway pressure (CPAP) device and humidifier.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has chronic heart failure 
with preserved ejection fractions. The Plan denied your request. The Plan says the clinical effectiveness has not 
been demonstrated. 
 
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 the requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). The clinical study on which the 
food and drug administration (FDA) approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
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 meets criteria for admission to an IRF. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee can 
get the services they need in another setting. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is necessary based 
on the complexity of the enrollee's current medical condition. The Plan denied your request. The Plan says the 
enrollee does not meet all the requirements for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
extremity. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is needed to rule of a rotator cuff tear in the 
shoulder. The Plan denied your request. The Plan says there is no documentation of formal physical therapy. 
 
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 the 
MRI of the upper extremity is not medically necessary. Our physician reviewer found that the enrollee has 
shoulder pain following a fall onto their left shoulder. The x-ray showed mild degenerative changes. The 
enrollee had tried ice, heat, and Voltaren gel. The enrollee also reported trying exercises which helped some. 
The MRI was requested to rule out rotator cuff tear in the shoulder. However, the provided records did not 
clearly describe the enrollee having recently tried at least 6 weeks of formal physical therapy, nor was there 
documentation of instructions for the home exercises that he was doing to objectively show that the enrollee 
had fully tried conservative treatments prior to consideration of advanced imaging. Also, physical findings did 
not include signs of red flag diagnoses that might warrant earlier consideration of advanced imaging. 
 
  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 imaging (MRI) of the upper extremity.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the brain 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an MRI scan of brain to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria 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 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 
a magnetic resonance imaging (MRI) scan of the brain to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88187, 88341 and 88342). 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. As the CPT code 88341 
was not billed an appropriate primary code that is not eligible for payment to the same practitioner for the same 
patient on the same date of service; we find that Medicare rule for payment for CPT code 88341 has not been 
met. If the provider determines that a billing error occurred during the initial submission of the denied claim, 
the Plan will accept a submission of a corrected claim to consider services for payment. Uphold the denial for 
procedure codes 88187 and 88342. National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) 
edit exists between 88189 and 88187 & 88342. This PTP edit has a modifier indicator of 1, modifiers 
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code 
edit. Therefore, we decided that the Plan does not have to pay for the laboratory services (88187, 88341 and 
88342).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 7, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization with angioplasty services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your 
symptoms are not typical for poor circulation. 
 
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 the requested services. Our physician 
reviewer found that you are status post numerous interventional procedures on the arteries of both legs. The 
current plan is to obtain a computed tomography angiography (CTA). However, the result of this is not 
provided in the medical records. The duplex study provided suggests only infrapopliteal disease. Generally, 
intervention on the tibial arteries is avoided unless there are clear signs of limb threat. The flow study provided 
is not complemented with a conventional ABI or a complete pulse examination. Furthermore, it is not 
documented if you are having lifestyle limiting claudication although, as noted above, would not consider 
claudication a typical indication for tibial artery intervention. In summary, as the medical record indicates that 
the treatment plan is to obtain a CTA and does not demonstrate evidence of limb threat, the documentation 
does not support the medical necessity of the requested procedures. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revascularization with angioplasty services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you need this device. The Plan denied your request. 
The Plan says the criteria for approval has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and 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. 
 
The record shows you received the requested 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 pay for the dental services on September 26, 2022.