Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Magnetic Resonance Angiography (MRA) of the head without 
dye, and a Magnetic Resonance Imaging (MRI) of the brain with and without dye. 
 
You asked the Plan to pre-approve an MRA of the head without dye and an MRI of the brain with and without 
dye. You say that an MRA of the head without dye and an MRI of the brain with and without dye is medically 
necessary. The Plan denied your request. The Plan says that an MRA of the head without dye and an MRI of 
the brain with and without dye is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs and 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 an MRA of the head without dye and an 
MRI of the brain with and without dye. Our reviewer says that an MRA of the head without dye and an MRI of 
the brain with and without dye is medically necessary. Our physician reviewer found that you have a history of 
traumatic brain injury; remote. You have had at least two computed tomography (CT) scans of the brain, but 
each was without contrast enhancement. As such the possibility of tumor or a vascular malformation has not 
been excluded since those possibilities require visualization of blood vessels in the brain. The possibility of 
venous angioma, arteriovenous malformations (AVM) have not been excluded with unenhanced CT scans. The 
workup of adult seizure disorder requires more extensive imaging than unenhanced CT. You may have an 
underlying renal disease or hypersensitivity to iodinated contrast which would be contraindications to x-ray dye 
and the requested MRA and MRI exams would provide valuable information. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA of the head without dye and an MRI of the brain with and without dye. 
have been met. Therefore, we decided that the Plan has to pre-approve an MRA of the head without dye and an 
MRI of the brain with and without dye. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound of the leg. 
 
You asked the Plan to pre-approve the ultrasound. You say that this is needed to rule out possible deep vein 
thrombosis. The Plan denied your request. The Plan says presently, there is no physician order or clinicals to 
support this request. 
 
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 ultrasound. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no physical exam or justification in the medical records for the lower extremity doppler 
ultrasound and no order for the test in the submitted material. Per Medicare guidelines, an imaging test cannot 
be approved without a written physician's order. 
 
 
 
 
  
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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ultrasound of the leg.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Eliquis for the enrollee.  
 
 
 
  
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you are scared to live 
alone. The Plan denied your request. The Plan says that the records do not support that inpatient psychiatric 
care is needed. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you will improve in a reasonable period of time as you do not have suicidal or homicidal ideation 
noted or auditory or visual hallucinations and were compliant with treatment. It does not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care as you do not have dangerousness to self or others and were compliant with treatment. Our 
physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexmethylphenidate HCL ER for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Dexmethylphenidate HCL 
ER for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be met at a lower level of 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke then discharged to skilled nursing. You were then discharged home and have had ongoing weakness and mobility concerns despite 
home health physical therapy. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this will allow the enrollee to better 
control his glucose. The Plan denied your request. The Plan says the requirements for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
(CGM).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve scaling and root planing (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not support the Plan's reason for denial. The record 
indicates that the enrollee has comprehensive dental coverage which includes the requested service once per 
quadrant every 36 months. There was no documentation to indicate that the criteria have not been met 
Therefore, we decided that the Plan has to pre-approve scaling and root planing (D4341) for all 4 quadrants.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (onabotulinumtoxinA). 
 
You asked the Plan to pre-approve the Botox. You say that this is medically necessary to treat the enrollee's 
spasticity. The Plan denied your request. The Plan says the provider is not planning to buy/bill this drug. As 
such, Part D coverage must be used. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox (onabotulinumtoxinA).  
 
Benefits for the Botox 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 pay for acupuncture services provided on July 28, 2021 to November 
6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for acupuncture services. You say that these services were medically necessary, and 
the out-of-network provider is closer to your home. The Plan denied your request. The Plan says the services 
were provided out-of-network and were not approved in advance. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for acupuncture services provided on July 28, 2021 to 
November 6, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast (zoledronic acid) injections. 
 
You asked the Plan to pre-approve the Reclast treatments. You say that the enrollee requires this drug to treat 
her osteoporosis. The Plan denied your request. The Plan says the enrollee's kidney function is too low to 
approve this medication. 
 
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 Reclast treatments. Our reviewer 
says that the requested drug is not considered reasonable and necessary as it is contraindicated for this enrollee. 
Our physician reviewer found based on the medical records provided and the Medicare-approved major drug 
compendia, the documentation does not support that the Reclast is safe and effective for the patient as her 
calculated creatinine clearance is 33 mL/minute (by Cockcroft-Gault) based on a creatine of 1.37mg/dL, height 
of 63 inches and weight of 69 kg at age 84. Reclast is contraindicated in patients with creatinine clearance less 
than 35 mL/minute.  
 
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 Reclast treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Reclast (zoledronic acid) injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on December 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate 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 the computed tomography (CT) scan of the head/brain rendered 
on December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81279, 81402, 81219). 
 
You asked the Plan to pre-approve the genetic testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says coverage rules are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that this genetic test is covered when JAK2 V617F 
mutation analysis was previously completed and was negative. 
 
We looked at the file and Medicare rules. The record shows the enrollee has already tested positive for JAK2 
V617F mutation. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81279, 
81402, 81219).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on July 21, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the imaging services. You say that service was provided to the enrollee out of 
medical necessity, and you would like the claim paid. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the imaging services provided on July 21, 2021, 
by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 29, 2021 to January 
12, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on December 29, 2021 to 
January 12, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 19, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 36227 is 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 code 36227 is selective catheter placement, external carotid 
artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological 
supervision and interpretation (List separately in addition to code for primary procedure). 
 
We find that CPT code 36227 is not supported in the medical record. Specifically, the operative report does not 
contain documentation of a selective catheter placement of a unilateral external carotid artery with 
angiography. 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 pay for the surgical services rendered on March 
19, 2021.