Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urology visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the urology visit. You say that the services are 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a urology 
visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation (MAKOplasty) 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies haven't proven the use of this technique is helpful with total knee 
arthroplasty surgery. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is insufficient evidence in the medical literature that the Mako computer-assisted surgical 
navigation system improves patient outcomes. The documentation in the case file does not support that the 
Mako computer-assisted surgical navigation system is medically reasonable and necessary for the enrollee in 
this case. 
 
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 computer-assisted surgical navigation (MAKOplasty) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography angiography (CTA) of the head and 
neck, and cerebral perfusion analysis provided to the enrollee on October 31, 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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 70496, 70498, 0042T are not supported in the medical record. Specifically, for CPT 
70496 and 70498, these codes were rendered in the intensive care unit (ICU) not the emergency room (ER) as indicated by the place of service 23 that was used on the claim. Additionally, 0042T was billed modifier GZ, 
which indicates that the service is not reasonable and necessary. 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 computed tomography angiography (CTA) of the head and neck, and cerebral perfusion 
analysis provided to the enrollee on October 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are very important for the enrollee to 
receive at home as soon as possible. The Plan denied your request. The Plan says this is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the documentation doesnt support that the enrollee requires additional skilled nursing services or skilled rehab 
services to provide treatment that is medically necessary. The enrollee does not require additional skilled 
nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the 
members condition, perform a maintenance program to maintain the members condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transport trips (A0100). 
 
You asked the Plan to pre-approve the additional routine transport trips. You say that the additional trips are 
medically necessary to attend doctor's appointments. The Plan denied your request. The Plan says the benefit 
has been exhausted. 
 
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 transport trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 27, 
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 denied codes remain not supported. 
 
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 the denied codes is: 
 
 
 CPT 87150: 
 
Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or 
isolate, each organism probed 
 
CPT 87640: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique 
 
CPT 87641: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, 
amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 laboratory report does not 
support any of these services as a distinct or independent procedure from CPT 87801. The use of modifier -59 
is not supported 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 laboratory services provided to the enrollee on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0857, E2363). 
 
You asked the Plan to pre-approve the group 3 power wheelchair. You say that the group 3 power wheelchair is 
medically necessary. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair (K0857, E2363).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a three level facet joint injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there must be sufficient documentation to support an injection of three levels. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no specific documentation indicating medical necessity for a three-level procedure 
bilaterally. The review has determined that there is not medical necessity for a three level injection. The need 
for this has not been established in the documentation. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a three level facet joint injection for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Dronabinol for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the drug is not being used as a full therapeutic replacement for IV anti-emetic drugs 
that would have been administered at the time of the chemotherapy treatment. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
decreased appetite with colon cancer, and has failed other anti-emetics. There are studies that that support the 
use of this drug in the enrollee's situation. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Dronabinol for the enrollee.  
 
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 pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's condition does not meet 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 enrollee is receiving appropriate care at the present acute care hospital. He 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861) with power tilt/recline. 
 
You asked the Plan to pre-approve the Group 3 PWC with multiple power options. You say that it is felt this 
PWC is medically necessary. The Plan denied your request. The Plan says the criteria for the requested PWC 
are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options may be 
covered for enrollees who either require a mounted ventilator or meet the criteria for a power tilt and recline 
seating system. 
 
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 Group 3 PWC with multiple power 
options. Our reviewer says that the criteria for the requested PWC base are not met in this case. Our physician reviewer found the documentation does not support that the patient is at high risk for pressure ulcer. He has 
been a manual wheelchair user without pressure ulcer, has no current ulcer, and no prior skin flap surgery. The 
patient does not use intermittent catheterization or have evidence of true spasticity and his tone was noted to be 
normal. A Group 3 power wheelchair with multiple power options and associated accessories is not medically 
necessary per the relevant LCD. 
 
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 Group 3 PWC with multiple power options have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861) with power tilt/recline.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alimta/Pemetrexed and Pembrolizumab/Keytruda for 
the enrollee. 
 
You asked the Plan to pre-approve this drug regimen. You say that this is medically necessary. The Plan denied 
your request. The Plan says the use of the combination of pemetrexed and pembrolizumab is not recommended 
for 
advanced non-small cell lung cancer which has progressed on a PD-L1 inhibitor, and there is lack of support 
for this use in the Medicare references. 
 
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 this drug regimen. Our reviewer says 
that the requested drug regimen is not medically reasonable or necessary. Our physician reviewer found that 
Pemetrexed is not considered a standard of care as an addition to immunotherapy for patients that have 
progressed on single agent immunotherapy. This use is not Food and Drug Administration (FDA) approved, 
supported by major drug compendia or the medical literature. The service is not reasonable or 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 this drug regimen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Alimta/Pemetrexed and Pembrolizumab/Keytruda for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found that the 
medical records do not address the need for this item. There is no indication that portable tanks will not meet 
your needs. There is no testing to demonstrate that you are able to maintain Sp02 higher than 91% at 1 to 4 
Lpm flow using an oxygen conserving device. The background indicates that you have been provided with E-
tanks for portability, although elsewhere it says you already have a portable oxygen concentrator. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs a SNF as they can't get any 
caregivers at home. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
continued stay at a SNF. 
  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 services. Our reviewer says that 
the enrollee does not qualify for SNF coverage. Our physician reviewer found that the enrollee does not have 
documented skilled nursing or skilled therapy needs. The enrollees care needs can be provided at a lower 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an upper gastrointestinal endoscopy 
(43239) provided at an ambulatory surgical center on December 17, 2021. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you had a colonoscopy and should 
not have a copayment. You also say you spoke to a Plan representative who advised you that you should only 
have a specialist copayment and the procedure itself would be covered. You do not agree with the copayment 
applied. The Plan denied your request. The Plan says the copayment was applied correctly. The Plan reviewed 
your call history and verified you contacted a representative after the endoscopy procedure. The Plan found you 
were misinformed about the copayment. Furthermore, the Plan contacted the provider and confirmed you 
received an endoscopy on December 17, 2021. You also received a colonoscopy, but that procedure occurred 
on a different date of service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for each ambulatory surgical center visit.  
 
 You have been asked to pay a $200 copayment for an endoscopy. Endoscopies falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. The service at issue was provided in an ambulatory surgical center. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an upper gastrointestinal endoscopy (43239) provided at an ambulatory surgical 
center on December 17, 2021.