Persius/hicric huggingface dataset:
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 LTACH care is medically reasonable for 
the enrollee's condition. 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 that in this case the enrollee was admitted for metabolic encephalopathy in the setting 
of urosepsis. The record indicates that the enrollee is improving but requires ongoing acute care services until 
he is ready to transition to a lower level of care. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy sessions for the enrollee. 
 
You asked the Plan to pre-approve the additional sessions. You say that this is medically necessary. The Plan 
denied your request. The Plan says this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy 
generally is not accepted as specific and effective therapy for the patients condition beyond what was 
approved by the health plan. The patient has had prior therapy and the documentation does not reveal that the 
patient requires the unique skills of a professional therapist to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or  by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the patient's current condition or to prevent or slow further deterioration. There has been instruction in an 
independent home program. Ongoing skilled therapy is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy sessions for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Forteo. 
 
You asked the Plan to pre-approve Forteo. You say that Forteo is medically necessary. The Plan denied your 
request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
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 Forteo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
May 18, 2022, forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that this care 
remains medically necessary. The Plan denied your request. The Plan says the rules for continuation of 
inpatient psychiatric care have not been met. 
 
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 the continuation of inpatient mental 
health care. Our reviewer says that the requested continuation of inpatient psychiatric care is not medically 
reasonable and necessary. Our physician reviewer found This 74-year-old female was admitted to the acute 
inpatient psychiatric hospitalization on April 22, 2022, with Major Depressive Disorder, Recurrent, Severe with 
Psychotic Symptoms and Generalized Anxiety Disorder. Based upon review the records provided it was not 
expected this enrollee would improve in a reasonable period of time for the dates in question as she did not 
have suicidal or homicidal ideation, auditory or visual hallucinations. The patient was compliant with treatment 
while not showing any acute threats to safety. It did 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 beyond the dates 
in question as she did not have dangerousness to self or others and was compliant with her treatment. 
 
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 continuation of inpatient mental health care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
May 18, 2022, forward.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 21, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service January 21, 
2022.
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 LTACH care is medically reasonable 
and necessary. 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 was admitted from an LTACH facility after being found unresponsive 
and in cardiac arrest while recovering from COVID-19 pneumonia. The record indicates that the enrollee 
remains clinically unstable with a bronchopleural fistula and remains on mechanical ventilation. The enrollee 
continues to receive acute care services, and these have not been denied. The medical record does not indicate 
that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 
facility. The elements of the coverage rules are not satisfied.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 13, 
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 appropriate modifier was not billed with this edit. 
 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 imaging services provided to the enrollee on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due 
to for insufficient evidence of efficacy. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is experimental. More research is needed to show the safety and efficacy of this 
request for lower back pain. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of authorization for this drug is correct, because this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Imfinzi. Our reviewer says that the 
enrollee meets the Medicare criteria for Imfinzi. Our physician reviewer found the enrollee has had response to 
treatment without progression on recent computed tomography on May 2, 2022. This requested use is Food & 
Drug Administration (FDA) approved for the enrollee's diagnosis. Imfinzi is supposed as safe and effective and 
otherwise 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 Imfinzi have not been met. Therefore, we decided that the Plan has to pre-
approve use of Imfinzi.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glucose monitoring supplies (K0553) provided on November 
30, 2020. 
 
You asked the Plan to pay for glucose monitoring supplies. You say that this is supported in the records. The 
Plan denied your request. The Plan says a valid proof of delivery has not been submitted. 
 
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 glucose monitoring supplies (K0553) provided on November 30, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on May 25, 2021. 
 
You asked the Plan to pay for the dental service. You say that the procedure code used, and device provided 
was the only choice the dentist had. You also say that the dentist advised your plan should be familiar with this 
procedure and that they do not consider it to be dentures. The Plan denied your request. The Plan says partial 
denture is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the partial denture is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper 
denture (D5213) provided on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702) for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this device is the only available treatment for 
individuals with moderate to severe upper limb paresis. The Plan denied your request. The Plan says there is no 
evidence that the enrollee would be able to successfully use this device, as there was a lack of therapist 
assessment or device trial. 
 
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 at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase  participation in 
bimanual activities. There is insufficient literature in the peer reviewed publications to assess safety, efficacy, 
long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity 
paralysis/paresis from conditions such as multiple sclerosis, spinal cord injury  or other 
neuromuscular/neurological disease or injury. 
 
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 a MyoPro Motion G Orthotic device (L8702) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110) provided on June 29, 2020. 
 
You asked the Plan to pay for physical therapy services. You say that you have provided the medical records 
required to process the claim. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. In this case, the case record documents that the services at issue were 
provided by an NPP. Based on this information, we decided that Medicare rules for coverage of physical 
therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical 
therapy services (97110) provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an interval injection provided to the enrollee on November 15, 2021. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denial is appropriate given the clinical scenario. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 pay for the injection. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the injection is considered part of ongoing intrathecal therapy. The procedure is medically reasonable 
and necessary. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pay for 
an interval injection provided to the enrollee on November 15, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services (A0427, A0425) 
provided on December 21, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that previous ambulance charges 
were waived due to being a COVID-19 expense. The Plan denied your request. The Plan says this processed 
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 ground ambulance services.  
 
You have been asked to pay a $290 copayment for ambulance services. 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 (A0427, A0425) provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 27, 
2021. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code G0481 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 drug testing services provided to the enrollee on May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 31, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service January 31, 
2022.