Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tape, non-waterproof, per 18 square inches (CPT code 
A4450 x390) and tape, waterproof, per 18 square inches (CPT code A4452 x390). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says there was no provider rationale as to why more than the Medicare approved maximum 
quantity of waterproof and non-waterproof is medically needed to manage the wound. 
 
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 DME. Our physician reviewer 
found the review has determined that there is not a medical need in the medical records for additional units of 
the DME.  
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve tape, non-waterproof, per 18 square inches (CPT code A4450 x390) and tape, waterproof, per 
18 square inches (CPT code A4452 x390).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective 
right total knee arthroplasty (27447). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you need to stay in the hospital to 
recover after knee replacement. The Plan denied your request. The Plan says there is no documentation 
provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the knee replacement surgery may be safely performed with a 48-hour 
observational stay. The documentation does not show evidence you will require hospital services that would 
likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care associated with an elective right total knee 
arthroplasty (27447).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on December 2, 2021. 
 
You asked the Plan to pay for the services provided. You say that the operative report clearly delineates each 
procedure performed. The Plan denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 15733 is muscle, myocutaneous, or fasciocutaneous flap; 
head and neck with named vascular pedicle (i.e., buccinators, genioglossus, temporalis, masseter, 
sternocleidomastoid, levator scapulae). The CPT Code Manual definition of code 15860 is intravenous 
injection of agent (e.g., fluorescein) to test vascular flow in flap or graft. 
 
We find that CPT codes 15733 and 15860 are not supported in the medical record. The medical records 
provided do not describe the codes as billed. The medical records provided do not show that the service billed 
with the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgery 
services provided on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four bone replacement grafts (D4263 x4). 
 
You asked the Plan to pre-approve the bone replacement grafts. You say that the grafting material is placed 
within the socket to preserve the bone. You also say that bone grafting needs to be performed on the same day 
so that healing can occur. The Plan denied your request. The Plan says this service is not covered under the 
enrollee's benefit plan. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four 
bone replacement grafts (D4263 x4).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that the enrollee is too weak for the daughter to 
provide care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
admission or continued stay in a skilled nursing facility. 
 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, 
there is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge 
and judgment of a skilled professional nurse are not required to safely and effectively provide medically 
necessary and reasonable treatment. The records do not document the need for intravenous medications, new 
tube feeding or ostomy care or daily complex wound care. There is no documentation that daily skilled services 
are required. The patient is walking household distances with a rolling walker with supervision and is 
supervision for transfers. The provided records do not document a significant decline in the patients functional 
status to necessitate daily inpatient skilled therapy services. Based on the medical records provided, there is no 
documentation that the patient requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the home with home health care or in a long-term care facility on a part time basis appear 
appropriate 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee 
and left hip for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says notes are needed showing four weeks of stretches in the last six months. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the imaging. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found no physical 
examination is documented. X-rays of the right knee revealed degenerative osteoarthrosis but no fracture or 
effusion. No x-ray report of the left hip is included. There is no conservative plan of treatment. Without a red 
flag, the medical necessity of both MRIs has not been established. 
 
 
 
 
 
 
 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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the right knee and left hip for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that these dentures should be covered under 
your benefits. You also say that you still do not have dentures that fit correctly. The Plan denied your request. 
The Plan says the requested services exceed the frequency limitation under your contract. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on 
September 15, 2021 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) 
benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete 
maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular UTI panel (87086, 87186, 87500, 87801, 
87150, 87481, 87556, 87563, 87640, 87651, 87653, 87798). 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration and 
reprocessing of your claim towards payment. The Plan denied your request. The Plan says there is lack of 
support for the clinical utility of large multiplex PCR urinary tract infection panel tests. There is lack of data to 
suggest these panels alter medical decision making. 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the molecular UTI panel (87086, 87186, 87500, 87801, 87150, 87481, 87556, 87563, 87640, 87651, 87653, 
87798).
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 can benefit from LTACH 
services based on his current care needs. You say that he cannot be adequately cared for at home or a skilled 
nursing facility and an LTACH admission should be reconsidered. The Plan denied your request. The Plan says 
the enrollee's care needs can safely be received in another 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 that the enrollee is receiving appropriate care at the present setting. The enrollee does 
not require services at the LTACH that are not available at the setting 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) of the lungs 
for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says you must be a current smoker, or have quit smoking within the last 15 years. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee fulfills 
all of the criteria except for having quit smoking over 16 years ago. CMS criteria specify that the patient in 
order to qualify for LDCT must either be currently smoking or having quit within the past 15 years. The timing 
of having quit smoking greater than 15 years ago disqualifies the patient for LDCT according to CMS 
guidelines. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a low dose computed tomography (LDCT) of the lungs for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic consultation provided by a 
dentist/physician other than the requesting dentist/physician (D9310) and therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve a diagnostic consultation and parenteral drugs. You say that these services 
are necessary. The Plan denied your request. The Plan says these services are not covered by your dental 
benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a diagnostic consultation provided by a dentist/physician other than the requesting dentist/physician (D9310) and 
therapeutic parenteral drugs (D9612).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion therapy services provided on April 28, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was 
billed with an invalid code. 
 
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 S9338 is home infusion therapy, immunotherapy, 
administrative services, professional pharmacy services, care coordination, and all necessary supplies and 
equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9338 is not valid for Medicare purposes. Medicare uses another code for the reporting 
of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
infusion therapy services provided on April 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing 
services or skilled therapy services. The documentation does not support that it is medically reasonable and 
necessary to provide skilled services on a daily basis. As a practical matter, you do not require the necessary 
services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix 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 medical studies have not proven that this drug is helpful for treatment of stomach 
cancer. 
 
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 
Panitumumab  (Vectibix) monotherapy is not a standard therapy for the treatment of recurrent progressive 
metastatic gastric cancer. Its use is not approved by the Food and Drug Administration (FDA), supported by the 
major compendia, or the medical literature. The service is not reasonable or medically necessary and unlikely 
to be safe or effective. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a phrenic nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that you have no alternatives at this point. 
The Plan denied your request. The Plan says this service is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that you have central sleep apnea that appears to be at least in part caused by treatment of 
restless leg syndrome (RLS) with a narcotic, Fentanyl patches. The medical records show that an adaptive 
servo ventilation (ASV) titration sleep study was successful, and settings were recommended. It is stated 
elsewhere in the record that ASV failed. Documentation of that is not provided and the reason for failure is 
unclear. There is no documentation of the other treatments tried for the RLS. Further, phrenic nerve stimulation 
is not currently an accepted treatment for this condition and is considered experimental. Therefore, the phrenic 
nerve stimulator is considered not medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a phrenic nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation with bone or bone substitutes via a 
lateral open approach (D7951). 
 
You asked the Plan to pre-approve sinus augmentation. You say that you need this treatment. The Plan denied 
your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve sinus 
augmentation with bone or bone substitutes via a lateral open approach (D7951).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the external insulin pump (E0784).
You asked the Plan to pre-approve the external insulin pump. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that this item is covered if the coverage criteria listed in the Medicare Rules section 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 the external insulin pump. Our reviewer says that the service is not medically necessary. Our physician reviewer found the criteria require insulinopenia as evidenced by low c-peptide, this patient does not meet the criteria given; there is also not a clear rationale why a pump would serve this patient better than correctly dosed SQ insulin shots. 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 external insulin pump have not been met. Therefore, we decided that the Plan does not have to pre-approve the external insulin pump (E0784).