Persius/hicric huggingface dataset:
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the coverage criteria for admission to a LTACH has not 
been met. 
 
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 appears to be improving but still somewhat unstable and requires 
short-term additional acute care services that can safely be provided at the current facility until more stable for 
transfer. The enrollee does not require services at the LTACH that are not already available at the current 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way trips (A0100). 
 
You asked the Plan to pre-approve additional one-way trips (A0100). You say that you thought you had 
unlimited trips. The Plan denied your request. The Plan says your benefit plan does not cover more than 40 
one-way trips per plan year. 
 
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 40 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 one-way trips (A0100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left side stab phlebectomy (37765). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the left leg has had a prior procedure 
back in 2016. Records are attached. The Plan denied your request. The Plan says the enrollee did not meet the 
coverage criteria for the requested service. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the coverage criteria requires that, for stab phlebectomy to be covered, there have to 
be symptoms that persist despite conservative treatment six weeks after the saphenous reflux has been treated. 
The ablation portion of the procedure has already been approved. This has not yet been performed. The health 
plan does not provide for simultaneous tributary treatment at the time of saphenous treatment. A rationale for 
this is that many patients will experience satisfactory relief of symptoms with saphenous treatment alone.  
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left side stab phlebectomy (37765).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy treatments. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 skilled services are not necessary to restore or maintain function or to prevent 
deterioration of your condition. Our physician reviewer found that the additional requested therapy generally is 
not accepted as specific and effective therapy for an enrollee's condition beyond what was approved by the 
health plan. The record indicates that you have had prior therapy and the documentation does not reveal that 
you require the unique skills of a professional therapist to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. You can transition to an independent home 
exercise program with the already approved therapy and do not require ongoing skilled therapy beyond what 
was approved. 
 
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 8 additional physical therapy treatments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 appears to be improving and should only require short-term additional 
acute care services that can safely be administered at the current facility until more appropriate for a lower level 
of care. The enrollee does not require services at the LTACH that are not already available at the current 
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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. The Plan denied your request. The Plan says the drug is not 
approved for the enrollee's condition. 
 
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 Imfinzi. Our physician reviewer found 
that the enrollee has cholangiocarcinoma. He was previously treated with chemotherapy. The requested single 
agent Imfinzi is not FDA approved for the enrollee's condition. The requested use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
on August 5, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99232 is not supported in the medical record. Specifically, this code was billed with 
place of service 61 (comprehensive Inpatient Rehabilitation Facility). This service was billed with an 
inappropriate place of service. The claim is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on August 5, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say ff DME serves the same purpose as equipment already 
available to an enrollee, it is not considered reasonable and necessary. 
 
The file shows that the enrollee has a spinal cord stimulator. The records provided do not show that the 
enrollees current device is no longer working or has irreparable damage. The enrollees current device serves 
the same purpose as the requested service. Therefore, we decided that the Plan does not have to pre-approve a 
replacement spinal cord stimulator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria. 
 
 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 home health services. Our physician 
reviewer found that the enrollee has a past medical history of multiple comorbidities including dementia and 
hypertension. The clinical documentation does not show any medical status or medication changes. Therefore, 
home health nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit-to-stand frame/table system. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested sit-to-stand system has 
not been shown as superior to other standard treatments for your condition. There is no indication it would 
improve your function or general health. The sit-to-stand system is therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a combination sit-to-stand frame/table system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mutL homolog 1, colon cancer, nonpolyposis type 2 (MLH1) 
gene analysis; promoter methylation analysis (81288). 
 
You asked the Plan to pay for MLH1 gene analysis. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that tier 2 genetic tests are unlikely to impact 
therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care of the 
beneficiary and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. The MLHI gene analysis testing is list listed as a tier 2 genetic test. 
Thus, the requested test is not covered under Medicare. Therefore, we decided that the Plan does not have to 
pay for mutL homolog 1, colon cancer, nonpolyposis type 2 (MLH1) gene analysis; promoter methylation 
analysis (81288).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve the radiation therapy. You say that please review reprocess and approve 
according to contract as a medical necessity. The Plan denied your request. The Plan says the requested 
treatment does not appear to be medically reasonable and 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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to 
help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy of 
treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used when critical structures 
are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply 
to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin 
cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, using 
ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for daily simple 
simulations (also requested in this case) and/or IGRT for a technology for which need has not been established 
by published data or supported by consensus guidelines (many of which recommend against treatment with 
these devices in general- citations below) is not necessary.  My decision is unfavorable as billing for daily 
IGRT or daily simulations (also requested in this case) which would not be furnished in accordance with 
accepted standards of medical practice.  
 
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 radiation therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve image guided radiation therapy (IGRT) (G6001).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210) provided by an out-of-network provider on August 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that this provider is now in-network. 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 a comprehensive oral evaluation (D0150) and intraoral imaging (D0210) provided by an out-of-
network provider on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted breast surgery procedure coded 19499 provided on May 24, 2022.

You asked the Plan to pay for the unlisted breast surgery procedure. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable 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.

In this case, the CPT Code Manual definition of code 19499 is unlisted procedure, breast.

We find that CPT code 19499 is not supported in the medical record. Specifically, this code was billed with a valid CPT -4 code. This claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the unlisted breast surgery procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted breast surgery procedure coded 19499 provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (VIA Disc procedure). 
 
You asked the Plan to pre-approve the VIA Disc procedure. You say that the VIA Disc procedure is medically 
necessary. The Plan denied your request. The Plan says percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (VIA Disc procedure) is not medically 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 VIA Disc procedure. Our reviewer 
says that the VIA Disc procedure is not considered medically reasonable and necessary. Our physician 
reviewer found this is an experimental/ investigational procedure and therefore, the request is deemed not 
medically reasonable and 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 VIA Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level  
(VIA Disc procedure).