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

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need physical therapy post-surgery in order to 
be able to walk again. You say that you have been in rehabilitation since January 9, 2023, and havn't received 
any therapy because authorization has not been approved. The Plan denied your request. The Plan says that , 
based on the enrollee's current level of function, they do not need daily skilled services to be provided only on 
an inpatient basis in a SNF. The Plan says that the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is documentation that daily skilled services are required. The enrollee was 
previously reported to be independent with mobility, transfers and all activities. As of January 18, 2023, she 
was walking less than household distances with a two-wheeled walker with moderate to maximum assistance 
and was moderate assist for transfers and was moderate to maximum assist for activities of daily living. 
Provided records document a significant decline in the enrollees functional status compared to her recent 
baseline to necessitate daily inpatient skilled therapy 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2022, billed with 
codes 81400, 81225, 81226, 81401, 81479, 81406, 81220, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 
81283, 81291, 81306, 81328, 81291, 81306, 81328, 81335, 81350, 81355, & 81381. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 4, 2022, billed with codes 81400, 81225, 81226, 81401, 81479, 81406, 81220, 81227, 81230, 81231, 
81232, 81240, 81241, 81247, 81283, 81291, 81306, 81328, 81291, 81306, 81328, 81335, 81350, 81355, & 
81381.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-emergent ambulance transport service (A0428). 
 
You asked the Plan to pre-approve a non-emergent ambulance transport service. You say that based on medical 
documentation, there is overwhelming evidence to support the need for ambulance/stretcher transportation for 
this enrollee. The Plan denied your request. The Plan says the request is not medically necessary because the 
enrollee does not meet the criteria requirements outlined in Medicare rules for this service. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 a non-emergent ambulance transport 
service. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this enrollee on March 8, 2023. Based on the 
documentation, a stretcher van would be an appropriate means of transport. The documentation does not 
support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a 
fully equipped ambulance can provide for safe transport on March 8, 2023. There is no documentation that 
BLS or ALS monitoring or treatment is needed during transport. The documentation does not support that the 
ambulance transport on March 8, 2023, was medically reasonable and necessary for the 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 a non-emergent ambulance transport service have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a non-emergent ambulance transport service (A0428).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service October 14, 
2021. 
 
You asked the Plan to pay for procedure code 99497. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 
99223. 
 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 99497 
is a column II code to column I code 99223. 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 procedure code 99497 billed for date of service October 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) (77014, 
G6002). 
 
You asked the Plan to pre-approve IGRT. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational 
for the enrollee's condition. 
 
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 IGRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no available documentation for why IGRT is needed for a palliative treatment with a standard 4-
field AP-PA and opposed lateral field arrangement. Usually, IGRT is used when critical structures are abutting 
or in close proximity to the target that is being treated to high doses, i.e. stereotactic radiation or curative 
treatment of head and neck, lung and CNS malignancies. This situation does not apply to this enrollee receiving 
low-dose palliative radiation of 2.5 Gy x 15. The available records do not sufficiently document the need for 
IGRT.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT) (77014, G6002).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. If the enrollee has chronic CO2 retention, may benefit from bilevel positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) (77373, 
77470). 
 
You asked the Plan to pre-approve SBRT. You say that the requested services are a medical necessity for you. 
The Plan denied your request. The Plan says the requested services are experimental/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 SBRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that as a boost treatment in patients with high-risk disease, SBRT is not standard and arguably remains 
investigational in terms of efficacy and toxicity. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT) (77373, 77470).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ceftriaxone. 
 
You asked the Plan to pre-approve self-administered drug. You say that this is needed by the enrollee. The Plan 
denied your request. The Plan says this drug is not covered by Medicare 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 ceftriaxone.  
 
Benefits for self-administered 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chlorpromazine. 
 
You asked the Plan to pre-approve chlorpromazine. You say that the requested drug is medically necessary to 
treat the enrollee's condition. You also say that this drug is not being used for nausea. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare 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 chlorpromazine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for percutaneous image-guided injection, drainage 
or aspiration procedures on the spine or spinal cord; lumbar or sacral rendered on May 11, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service does not meet the coverage requirements. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that minor pain procedures under most routine circumstances do not require anesthesia care other than 
local anesthesia. In this case, the patient has no significant past medical history to warrant anesthesia services. 
The anesthesiologist documented that the enrollee has an American Society of Anesthesiologists (ASA) physical status of 2 (ASA 2, which is used for a patient with a mild systemic disease). There is no 
documentation in the patient's record indicating that it is medically necessary to have an anesthesiologist 
present during this injection. The medical necessity was not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the 
spine or spinal cord; lumbar or sacral rendered on May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GuardantReveal test rendered on September 14, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee is not currently on chemotherapy or target 
therapy, and does not currently have clinical, radiographic, or biologic evidence of recurrence or progression. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is insufficient data to recommend multigene assay panels to determine  need for adjuvant 
chemotherapy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the GuardantReveal test rendered on September 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee needs this service. The 
Plan denied your request. The Plan says you do not meet criteria for coverage because you are over the age of 
77. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is over 77 years of age. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services related to the Transcatheter 
Edge-to Edge Repair (TEER) procedure provided from May 3, 2022, through May 4, 2022. 
 
You asked the Plan to pay for inpatient hospital services. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim does not include the clinical trial number 
as required. 
 
The Plan must follow Medicare rules. Medicare rules say that as of January 1, 2014, providers must report the 
clinical trial number for services covered under CED, in value code D4. 
 
We looked at the file and Medicare rules. We find that the services rendered are covered under CED. The claim 
does not include value code D4. Based on this information, we decided that Medicare rules for coverage of 
inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services related to the Transcatheter Edge-to Edge Repair (TEER) procedure provided from 
May 3, 2022, through May 4, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper and lower partial dentures. 
 
You asked the Plan to pre-approve the dental services. You say that the items are necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 17, 2021. 
Therefore, we decided that the Plan does not have to pre-approve upper and lower partial dentures.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve omeprazole capsule. 
 
You asked the Plan to pre-approve omeprazole. You say that the requested drug is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare 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 omeprazole capsule.  
 Benefits for omeprazole 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. You say you are dizzy and having double vision. The Plan denied your request. The Plan 
says criteria for admission to the IRF setting have not been met. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350), diagnostic casts (D0470), core buildup, including any pins when required (D2950) 
Tooth #2 and 5, pontic  porcelain/ceramic (D6245) Tooth #3, and retainer crown  porcelain/ceramic (D6740) 
tooth # 2 and 5. 
 
You asked the Plan to pre-approve dental services. You say that the provider recommended you get the 
requested services to help with the pain and issues you are experiencing. The Plan denied your request. The 
Plan says this service is not covered under your 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. The 2D oral/facial 
photographic image obtained intra-orally or extra-orally, diagnostic casts, core buildup, including any pins 
when required, pontic  porcelain/ceramic, and retainer crown  porcelain/ceramic are not covered under the 
Plans dental benefits. 
 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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350), diagnostic casts (D0470), core 
buildup, including any pins when required (D2950) Tooth #2 and 5, pontic  porcelain/ceramic (D6245) Tooth 
#3, and retainer crown  porcelain/ceramic (D6740) tooth # 2 and 5.