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

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the care the enrollee is receiving is not medically 
necessary for inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. You were admitted 
because you were unable to care for yourself at home after being discharged the day prior, after hospitalization for a wrist fracture. Though transitional care unit (TCU) admission was recommended at the prior admission, 
you reportedly opted to be discharged home. Upon readmission, there were no new fractures or need for 
surgical intervention which required inpatient hospital admission. The the record did not show that at the time 
of inpatient admission the admitting physician reasonably expected that your necessary hospital care would 
span two midnights. Our physician reviewer found that your condition does not meet criteria for coverage of 
inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mohs micrographic surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of why this request is 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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that squamous cell carcinoma on the skin of pretibial lesion is not a direct indication for Mohs surgery. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Mohs micrographic surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek SmartView In Vitro test Strips. 
 
You asked the Plan to pre-approve Accu-Chek SmartView In Vitro test Strips. You say that these are medically 
necessary. The Plan denied your request. The Plan says that you have not tried and failed the preferred product. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of test strips. Without this, medical necessity cannot be 
established. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek SmartView In Vitro 
test Strips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need this 
transportation. The Plan denied your request. The Plan says that this request exceeds the benefit maximum. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zirabev, Oxaliplatin, 5-FU, Leucovorin IV, 
Palonosetron and Dexamethasone for the enrollee. 
 
You asked the Plan to pre-approve these drugs. You say that these drugs are medically necessary. The Plan 
denied your request. The Plan says that the use of this drug/regimen is not reasonable and necessary. 
 
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 these drugs. Our reviewer says that 
these drugs are not medically reasonable and necessary. The requested use of Zirabev, Oxaliplatin, 5-FU, 
Leucovorin IV, Palonosetron and Dexamethasone is not FDA-approved for the enrollees diagnosis. The use of 
these drugs is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of these 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 these drugs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zirabev, Oxaliplatin, 5-FU, Leucovorin IV, Palonosetron and Dexamethasone for the 
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system and transport brackets. 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you have advanced arthritis pain in 
both hands and left wrist, which makes transferring from your wheelchair onto other surfaces and transferring 
back into the chair difficult. You are requesting reconsideration for the denial of wheelchair accessories 
needed. The Plan denied your request. The Plan says a power seat elevation system is non-covered because 
they are not primarily medical in nature. The use of a power wheelchair is for use inside the home therefore, 
the transport bracket would be non-covered because it is for use outside the home. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that for equipment to be covered, it must be appropriate and needed for use 
inside the home. 
 
The power seat elevation system does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The transport 
brackets are for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan 
covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a 
power seat elevation system and transport brackets.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve travel accommodations for bariatric surgery. 
 
You asked the Plan to pre-approve travel accommodations. You say that you need this because providers in 
your area will not perform the service you need. The Plan denied your request. The Plan says travel expenses 
are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must provide reasonable 
accommodations for the enrollee and a companion while in the distant location for transplant services. 
 
We looked at the file and Medicare rules. Medicare provides travel accommodations only for transplant 
services. The requested travel accommodations are for bariatric surgery. Based on this information, we decided 
that Medicare rules for coverage of travel accommodations have not been met. Therefore, we decided that the 
Plan does not have to pre-approve travel accommodations for bariatric surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 lab services provided on December 16, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a general health panel provided on April 26, 2022. 
 
You asked the Plan to pay for the general health panel. You say that this general health panel was requested 
during an annual exam from your gynecologist. You say that your doctor has done this lab work every year 
with no problem. The Plan denied your request. The Plan says that the enrollee is responsible for paying the 
full cost of services not covered by the Plan. The Plan says that it is the enrollee's responsibility to become 
familiar with their benefits. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the general health panel by a contract provider. The file does not show that the Plan 
provided notice that the general health panel would not be covered. Under Medicare rules, this means the 
general health panel is considered approved by the Plan. Therefore, we decided that the Plan has to pay for a 
general health panel provided on April 26, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 36000. The Plan denied your request. The Plan says procedure 
code 36000 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 procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service March 22, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the hospital discharge day management services (99239) provided on 
December 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the maximum 
allowable has been exceeded. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that only one hospital discharge is allowed per stay. The 
documentation shows that only one unit of code 99239 was billed for the hospital stay in question, which is 
allowed by Medicare. The Plan has not provided documentation supporting its denial. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
hospital discharge day management services (99239) provided on December 13, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Furosemide for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under the enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Furosemide for the enrollee.  
 
 
 
 Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on March 23, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on March 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee indicates that the enrollee has  chronic low back pain and lumbar spinal stenosis with 
neurogenic claudication. The record indicates that the enrollee has multi level degenerative disease. The record 
does not document that the enrollee is not a candidate for operative intervention at no more than two 
levels. The elements of the coverage criteria are not satisfied. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the mental health services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
are non-emergent and can be provided in-network. 
 
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 
mental health services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Martin bionics socket and an adjustable stance flexion 
feature for the enrollee. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this exceeds the enrollee's medical need. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided there is no documentation that the Martin bionics socket and 
the adjustable stance flexion feature at issue in this case meet Medicare criteria for medically reasonable and 
necessary per Social Security Act, Section 1862(a)1(A). The provided records from the enrollee's treating 
physician do not document necessity of the requested equipment as required by Medicare rules.  
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Martin bionics socket and an adjustable stance flexion feature for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET/CT scan for the enrollee. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that they did not receive a detailed history that shows this study is 
needed. 
 
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. Our reviewer says that a 
PET scan is not medically reasonable and necessary. The enrollee has had a benign duodenal nodule. No data 
was presented to suggest carcinoid-type symptoms, to show elevated carcinoid serum markers, nor abnormality 
found on total body gallium scan. Nodule biopsy showed benign hyperplastic glandular epithelium. No follow-
up biopsies nor endoscopic re-evaluation have been pursued. The medical necessity of a dotatate PET/CT scan 
in this setting of a benign duodenal nodule, as evidenced by multiple modalities, is not demonstrated by the 
clinical data presented. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of a PET scan. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET/CT scan for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you require 
transportation. The Plan denied your request. The Plan says that this request exceeds the 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 sixty (60) 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.