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

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve additional routine transportation services. You say that additional routine 
transportation services are necessary at this time. The Plan denied your request. The Plan says the benefit for 
routine transportation have 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 60 one-way 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 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 the enrollee is suitable for transfer to an 
LTACH as she requires daily physician management with close medical monitoring. You say that she cannot 
be adequately cared for at home or in a skilled nursing facility and authorization should be granted. The Plan 
denied your request. The Plan says admission to an LTACH is not to be used as an alternative to completion of 
the full course of treatment in the referring hospital. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. 
 
  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: 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 the enrollee is ready for transfer as she 
requires continuation of acute treatment and high nursing needs that are unable to be met in a lower level of 
care. You say that the goal is to safely regain her prior level of function while preventing readmission in a 
lower level of care. The Plan denied your request. The Plan says the enrollees medical needs are being met in 
the current acute setting. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. 
 
  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: 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 you are recommending discharge to an 
LTACH for continued weaning from mechanical ventilation, monitoring labs, monitoring nutritional status, and 
continuing IV and fluid support. You say that a lower level of care is not medically equipped for complicated 
patients and the enrollee is ready to transition to LTACH level of care. The Plan denied your request. The Plan 
says criteria for admission to the LTACH have not been met as the enrollees medical needs are being met in 
the current acute setting. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. 
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast implant removal, revision of peri-implant 
capsule, and a peri-implant capsulectomy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that reconstructive surgery is covered when specific 
criteria are met. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the criteria for coverage states that 
removal or revision of breast implants is considered medically necessary when removed due to mechanical 
complication of breast prosthesis, infection or inflammatory reaction, or other complications including 
siliconoma, granuloma, interference with diagnosis of breast cancer, and/or painful capsular contracture with 
disfigurement. The records do not show that any of these conditions are present. The enrollee has chronic back 
pain due to intact breast implants. The criteria for coverage are not met and the services are not reasonable or 
medically necessary at this time. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve breast implant removal, revision of peri-implant capsule, and a peri-implant capsulectomy.
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. The Plan denied your request. The Plan says you can safely 
receive the services you need in other settings. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
  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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clindamycin phosphate injection (S0077) provided on 
November 18, 2021. 
 
You asked the Plan to pay for the clindamycin phosphate injection (S0077). You say that the charges are 
appropriate for the level acuity and intensity of the medical services provided. You say that the medical 
treatment notes verify the services and additional payment should be made. The Plan denied your request. The 
Plan says procedure code S0077 is not recognized by Medicare for outpatient claims and the remaining codes 
were handled under a separate case. 
  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 code S0077 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S0077 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the clindamycin phosphate injection (S0077) have not been met. Therefore, we decided that the 
Plan does not have to pay for the clindamycin phosphate injection (S0077) provided on November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the myocardial perfusion imaging, tomographic 
(SPECT) (CPT code 78452). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. The Plan states CPT code(s): 93015, 
A9502, and J2785 do not require prior authorization. 
 
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 service. Our physician reviewer 
found there was insufficient support made for SPECT vs exercise stress test for this clinical situation. The NCD 
for Medicare coverage was not 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the myocardial perfusion imaging, tomographic (SPECT) (CPT code 78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
August 31, 2021. 
 
  You asked the Plan to pay for hospital discharge day management (99239). You say that since there are two 
different specialties, both providers are entitled to separate reimbursement. You say that the records should be 
reviewed, and the claim processed accordingly. The Plan denied your request. The Plan says only one hospital 
discharge day management service is payable per patient per hospital stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules so that only one hospital discharge day management service is payable per patient per hospital 
stay. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the Plan already paid for 
hospital discharge day management; 30 minutes or less (99238) provided on August 31, 2021. Based on this 
information, we decided that Medicare rules for coverage of hospital discharge day management (99239) have 
not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management 
(99239) provided on August 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carvedilol. 
 
You asked the Plan to pre-approve Carvedilol. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Carvedilol.  
 
Benefits for Carvedilol 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on 
February 5, 2022. 
 
You asked the Plan to pay for CT scan 70450. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70450 has a procedure-to-procedure (PTP) edit of 1 with code 70496 so is not separately payable without an 
appropriate modifier. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on 
February 5, 2022.
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 would benefit from acute rehab to return 
home to independent level which was her prior level of function. The Plan denied your request. The Plan says 
care can be received in alternate settings such as a skilled nursing facility, outpatient setting or home health 
care. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa 20MG/2ML (CPT code J7323). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee had no significant improvement in 
pain and functional capacity achieved with prior series of viscosupplementation and intraarticular steroid 
injections to the knees. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the previous viscosupplementation injections (with Gel-One) provided no relief of pain. The review has 
determined that the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. 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 medication have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Euflexxa 20MG/2ML (CPT code J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Alzheimer's Dementia NGS panel (81479, 81408, 81406, 
81405, 81404, 81401 and 81251) provided November 23, 2020. 
 
You asked the Plan to pay for the laboratory service. You say that please review the appeal and medical records 
to prove medical necessity. The Plan denied your request. The Plan says screening genetic testing is not a 
covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Medicare rules say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. 
 
The test at issue in this appeal, the laboratory service, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Also, the performance of multiple molecular tests 
regardless of whether the requisition lists the tests as a panel or individually and completed on a single sample 
is considered to be a Panel of tests and should be billed under a single CPT code to prevent stacking of codes. 
Therefore, we decided that the Plan does not have to pay for Alzheimer's Dementia NGS panel (81479, 81408, 
81406, 81405, 81404, 81401 and 81251) provided November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), lens (V2200), and polycarbonate lens 
(V2784) provided on December 7, 2021. 
 
You asked the Plan to pay for the frames, lens, and polycarbonate lens. You say that the last glasses payment 
you submitted was for the 2020 plan year, not the 2021 plan year. You also say that you would like the Plan to 
reconsider this denial for reimbursement for the vision hardware. The Plan denied your request. The Plan says 
the vision hardware you purchased on February 26, 2021 reached and paid your $150 maximum calendar year 
benefit for vision hardware. The Plan also says that this 2021 date is supported by the receipt you submitted for 
the hardware purchased. 
 
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 up to $150 every year. 
 
We looked at the file and the Plan's rules. Specifically, you received vision hardware on February 26, 2021 and 
exhausted your $150 vision hardware benefit. Based on this information, we decided that the Plan's rules for 
coverage of the frames, lens, and polycarbonate lens have not been met. Therefore, we decided that the Plan 
does not have to pay for the frames (V2020), lens (V2200), and polycarbonate lens (V2784) provided on 
December 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110) provided on October 21, 
2021. 
 You asked the Plan to pay for physical therapy. You say that these services were medically necessary and were 
billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy services were 
being rendered. The incident-to requirements have not been met in this case. Based on this information, we 
decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services (97110) provided on October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HC Pramoxine 2.5-1% cream. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says this is a self-administered drug and does not fall under Part B 
coverage. 
 
 
 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 HC Pramoxine 2.5-1% 
cream.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (CPT code 99214) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there are in-network providers able to provide the services. 
 
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 
the office visit (CPT code 99214) to be provided by an out-of-network provider.