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 the enrollee would benefit and be safest 
at a long-term acute care hospital. The Plan denied your request. The Plan says rules for LTACH care have 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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, and 84295 billed for date of 
service November 3, 2021. 
 
You asked the Plan to pay for procedure codes 82435, 84132, and 84295. You say that you have provided 
medical records to support payment for these services. The Plan denied your request. The Plan says payment 
for codes 82435, 84132, and 84295 is bundled into payment for code 80051. 
 
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 codes 
82435, 84132, and 84295 are column II codes to column I code 80051. 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 codes 82435, 84132, and 84295 
billed for date of service November 3, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain without contrast 
(70551). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that this service is not medically necessary for the enrollee. 
 
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 this service. Our reviewer says that this 
service is medically necessary. Our physician reviewer found that the report of the MRI of the thoracic spine 
done on July 28, 2022 showed an abnormal appearance of the thoracic cord. As such, analysis of the entire 
cerebrospinal tract including the brain is necessary in order to rule out a central nervous system (CNS) primary 
tumor with drop metastasis. Thus, an MRI of the brain is 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 this service have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the brain without contrast (70551).  
 
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: 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 enrollee did complete his stay in the 
current facility and is stable for discharge and exceeds the Medicare criteria for the LTACH. The Plan denied 
your request. The Plan says authorization denied because the LTACH is not medically necessary, and all 
services being provided in the current acute care setting is already approved. 
 
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 there is no evidence that the enrollee requires services that are not currently 
available. LTACHs and Adult Care Home (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH.  
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (leads and lead wires) 
provided on March 1, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation submitted did not sufficiently support the billed supply codes. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the electrical stimulator supplies (leads and lead wires) 
provided on March 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for admission to an SNF are not 
met in this case as the documentation does not support that the enrollee requires daily skilled therapy services. 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided, there is no documentation that the 
enrollee requires skilled nursing services which require the specialized skill, knowledge and judgement of a 
skilled professional nurse in order to safely and effectively provide medically necessary treatment. Records do 
not document the need for intravenous medications, new tube feeding, ostomy care or daily complex wound 
care or respiratory care. The records do show that the enrollee requires skilled therapy services; however, the 
records do not document a significant decline in the enrollees functional status which would necessitate skilled 
therapy services on a daily inpatient basis only in a skilled nursing facility setting. Based on the documentation 
provided, the enrollee could safely receive the necessary services in the home or an assisted living facility with 
home health care or in a long-term care facility on a part time basis. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary and 
have been the consistent treatment over the past 5 years and approved historically. The Plan denied your 
request. The Plan says the requested item is not covered under Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0730) provided on April 24, 2022. 
 
You asked the Plan to pay for a TENS device. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0730) provided on April 24, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the portable oxygen concentrator. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you would like the Plan to 
reconsider their denial of payment. 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. The Plan's only denial rationale is that they were unable to verify with the Plan's 
network provider if they directed the enrollee to the out-of-network durable medical equipment supplier. The 
file shows that the network provider has the name of the out-of-network supplier in their system. The Plan has 
not provided enough evidence to show that the network provider did not direct the enrollee to the out-of-
network supplier. Therefore, we decided that the Plan has to pay for the portable oxygen concentrator.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261), hearing aid or assistive listening 
device/supplies/accessories (V5267), and sales tax (S9999) provided on March 2, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the hearing aids, hearing aid or assistive listening device/supplies/accessories, 
and sales tax. You say that you were initially told the devices were covered. The Plan denied your request. The 
Plan says there is no coverage if hearing aids, or related services are received from an OON provider. The Plan 
also says that you contacted the Plan after you purchased these hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids, hearing aid or assistive listening device/supplies/accessories, and sales tax have 
not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261), hearing aid 
or assistive listening device/supplies/accessories (V5267), and sales tax (S9999) provided on March 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the pelvis with contrast 
(72196). 
 
You asked the Plan to pre-approve an MRI of the pelvis with contrast. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service at issue is not medically necessary. 
 
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 an MRI of the pelvis with contrast. Our 
reviewer says that the requested services are medically necessary and reasonable. Our physician reviewer found 
the enrollee is described in the chart as morbidly obese and has never been sexually active. The endometrium 
must be evaluated in a patient with spotting at this age. In addition, the bladder must be evaluated due to the 
description of same in the ultrasound report. It is not reasonable to attempt a transvaginal ultrasound on a 
patient at this age who has never been sexually active. In addition, a transvaginal ultrasound would not evaluate 
the urinary bladder. 
 
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 MRI of the pelvis with contrast have been met. Therefore, we decided that 
the Plan has to pre-approve magnetic resonance imaging (MRI) of the pelvis with contrast (72196).  
 
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: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on February 15, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes the 
FANCC gene, the denial is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to an enrollee with non-small cell lung 
cancer. The FDA approval notice indicates that this panel is approved for non-small cell lung cancer. No other 
valid denial rationale was presented by the Plan. Based on this information, we decided that Medicare rules for 
coverage of the F1CDx testing have been met. Therefore, we decided that the Plan has to pay for the 
FoundationOne CDx (F1CDx) testing provided on February 15, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Medtronic Infuse BMP-2 Allograft. 
 
You asked the Plan to pre-approve a Medtronic Infuse BMP-2 Allograft. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 a Medtronic Infuse BMP-2 Allograft. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the requested Medtronic Infuse BMP-2 Allograft, in this case, is not medically reasonable or 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 a Medtronic Infuse BMP-2 Allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Medtronic Infuse BMP-2 Allograft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered drug provided on March 16, 2022, and 
March 17, 2022. 
 
You asked the Plan to pay for a self-administered drug. You say that the services were medically necessary. 
The Plan denied your request. The Plan says self-administered medications are not covered under the Part B 
plan. 
 
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 pay for a self-administered drug 
provided on March 16, 2022, and March 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on July 30, 2020. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 60-day episode of care. 
 
We looked at the file and Medicare rules. The file shows that the claim represents the first 30 day period of the 
plan of care and was paid at the rate for late timing. Therefore, we decided that the Plan does not have to pay 
for the home health services rendered on July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular electrical stimulation (NMES) rendered 
on March 22, 2022. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that coverage for NMES/FES for walking will be covered 
in spinal cord injury (SCI) patients that meet specific criteria. 
 
We looked at the file and Medicare rules. The file shows that the services were not rendered for spinal cord 
injury. 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 neuromuscular electrical stimulation 
(NMES) rendered on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that you believe this claim was denied due to not prior 
authorization.  You said that this should be reconsidered because these labs were ordered by the referring 
physician. The Plan denied your request. The Plan says the patient was enrolled in hospice on the date of 
service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for lab services provided on February 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid 
analysis for lymphedema assessment (93702). 
 
You asked the Plan to pre-approve the diagnostic service. You say that in your medical opinion the enrollee is 
at a high risk of developing lymphedema and you believe the use of the L-Dex device is medically necessary. 
The Plan denied your request. The Plan says there are not enough studies on Bioimpedance spectroscopy to 
show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pre-
approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment (93702).