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

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic recording.  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any documentation of any anticoagulation therapy or atrial 
fibrillation. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has had no documentation of significant arrhythmias. There is no evidence that standard 
electrocardiogram monitoring would not be sufficient in this clinical setting. In summary, there is insufficient 
documentation to support the medical necessity for external mobile cardiovascular telemetry in this patients 
clinical management. 
 
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 pre-approve external mobile cardiovascular telemetry with electrocardiographic recording.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110, 97112, 97116, and 97150 billed for 
date of service June 27, 2022, to June 28, 2022. 
 You asked the Plan to pay for procedure code 97110, 97112, 97116, and 97150. You say that the 
documentation supports the services rendered. The Plan denied your request. The Plan says an appropriate 
modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 97110 is a column II code to column I code 92526. Code 97112 is a 
column II code to column I code 92526. Code 97116 is a column II code to column I code 97150. Code 97150 
is a column II code to column I code 92526. The codes at issue have 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 97110, 97112, 97116, and 97150 
billed for date of service June 27, 2022, to June 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical total disc arthroplasty. 
 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says it cannot be said that is reasonable and necessary at this time. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has had a previous cervical fusion. Total disc replacement is experimental when 
combined with previous cervical fusion. More research is needed. 
 
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 pre-approve cervical total disc arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abiraterone tablet 250mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Abiraterone tablet 250mg.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on 
September 29, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for outpatient diagnostic test/Medicare-covered outpatient diagnostic procedure.  
 
You have been asked to pay a $50 copayment for outpatient diagnostic test. However, you are only being asked 
to pay $18.33 which is less than the required amount. This item/service falls within the outpatient diagnostic 
test/Medicare-covered outpatient diagnostic procedure benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for outpatient diagnostic test provided on September 29, 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 the enrollee needs SNF care The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for a SNF admission. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 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: 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 you are unstable and cannot care for yourself. The 
Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement. however, the documentation does not indicate that you would require skilled rehabilitation in an IRF; participating in rehabilitation services 15 hours per week under physician 
supervision. You can receive further care at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services and outpatient hospital 
services provided on September 22, 2022, to October 24, 2022. 
 
You asked the Plan to waive the copayment for ambulance services and outpatient hospital services. You say 
that you disagree with the copayments. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment for ambulance services and a $300 copayment for outpatient hospital services/advanced imaging 
services.  
 
You have been asked to pay a $290 copayment for ambulance services and a $300 copayment for outpatient 
hospital services. The total amount you are being asked to pay is $590 ($290 +$300 = $590). This item/service falls within the ambulance services and outpatient hospital services/advanced imaging services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for ambulance services and outpatient hospital 
services provided on September 22, 2022, to October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 CGM. 
 
You asked the Plan to pre-approve a Dexcom G6. You say that the Dexcom G6 CGM is medically necessary. 
The Plan denied your request. The Plan says the Dexcom G6 is not a preferred product. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Dexcom G6. Our reviewer says that that the coverage criteria for a Dexcom has not been met. Our physician reviewer found that the enrollee does 
not specifically need the Dexcom CGM instead of the Plan's preferred product. The enrollee does meet the 
coverage criteria for a CGM, and the preferred brand should provide similar alarms for high and low blood 
glucose sugar levels. 
 
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 Dexcom G6 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6 CGM.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure codes J1955, J3411, J3415, 
J3490) provided to the enrollee on September 7, 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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) J3411: 
 
Injection, thiamine hcl, 100 mg 
 
HCPCS J1955: 
 
Injection, levocarnitine, per 1 gm  
HCPCS J3415: 
 
Injection, pyridoxine hcl, 100 mg 
 
HCPCS J3490: 
 
Unclassified drugs 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the records show that the 
medications in question were mixed and injected at four separate locations. There is a more appropriate code to 
use when a compound medication is injected. 
 
We looked at this coder'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 injection services (procedure codes J1955, J3411, J3415, J3490) provided to the enrollee on 
September 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 31, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says you did not bill these ambulance services correctly in 
accordance with Medicare billing rules. 
 
The Plan must follow Medicare rules. Medicare rules say that the MUE for code A0425 is 250 miles. If you 
report this code with units greater than the MUE, the line or claim will be denied. In this case, you billed 262.7 
units of code A0425, exceeding the MUE allowed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided on May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation. 
 You asked the Plan to pre-approve transurethral waterjet ablation. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules state that water vapor thermal therapies for LUTS/BPH are 
only covered under certain conditions. 
 
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 transurethral waterjet ablation. Our 
reviewer says that the enrollee does not meet criteria for this procedure. Our physician reviewer found the 
enrollee is not a poor candidate for other surgical interventions for benign prostatic hyperplasia (BPH) due to 
underlying disease and may have an active urinary tract infection due to indwelling Foley catheter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transurethral waterjet ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective internal radiation treatment (SIRT). 
 
You asked the Plan to pre-approve SIRT. You say that this is needed so the enrollee can have less need of pain 
medications, improved mobility and activity, and healthier living. The Plan denied your request. The Plan says 
this procedure is 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 SIRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
procedure to be a safe and/or effective treatment for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SIRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve selective internal radiation treatment (SIRT).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 22, 2022, to 
July 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you provided medical records to 
support payment. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 22, 2022, to July 
21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (90867, 90868, 
90869).  
You asked the Plan to pre-approve transcranial magnetic stimulation. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve transcranial magnetic stimulation. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does have a diagnosis of major depressive disorder, recurrent severe 
without psychotic features. However, the documentation available for review doesnt contain an order for 
rTMS by a physician who has examined the enrollee. The only documentation available for review is from an 
Intake Coordinator. Furthermore, the documentation doesnt support that the enrollee has tried at least 4 
different medications for the treatment of the current depressive episode without successful improvement in 
symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcranial magnetic stimulation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transcranial magnetic stimulation (90867, 90868, 90869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test predicts the response to tumor necrosis 
factor alpha inhibitor (TNFi) therapies. The Plan denied your request. The Plan says the test as a standard of 
care has not been demonstrated. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are no medical records from the treating physician 
to show that the results of testing will impact clinical management. This testing is not covered for screening 
purposes. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing services provided on July 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services designated with procedure code 87505 and 
provided on February 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services designated with procedure code 87505 and provided on February 
18, 2022.