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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the diagnostic criteria of both 
Alzheimer's disease and frontotemporal dementia. There is no indication that the examination is being 
requested in the context of a clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is only covered when there is a 
need to separate a differential diagnosis of frontotemporal dementia and Alzheimers disease. 
 
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 PET scan of the brain. Our reviewer 
says that the requested service is not medically necessary. Our physician reviewer found the information 
provided for review did not demonstrate that the enrollee met criteria for either AD or FTD, let alone both 
conditions. In as much the enrollee would not meet/satisfy the baseline requirement for coverage of the 
requested service as defined by the NCD. 
 
   
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
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 acute inpatient rehabilitation is medically necessary. 
The Plan denied your request. The Plan says your ongoing skilled therapy and nursing needs can be provided at 
a lower level of care such as at a Skilled Nursing Facility, on an intermittent basis at home with home health 
care, or in a long-term care setting. 
 
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 there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
 
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: 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 the services are medically necessary to maximize the 
enrollees functional mobility and safety before they return home. The Plan denied your request. The Plan says 
the enrollee's needs can be met at a skilled nursing facility, with home health care or outpatient therapy 
services. 
 
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 the enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service February 7, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 87481, 
87653, and 87798 are bundled into payment for code 87801. 
 
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 
87481, 87653, and 87798 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit as the records do not support the use of modifier 91 with these codes. 
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 87481, 87653, and 87798 billed for date of service February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service 
September 13, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was ordered based on medical 
necessity. The Plan denied your request. The Plan says the coding is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87899 is infectious agent antigen detection by 
immunoassay with direct optical (i.e., visual) observation; not otherwise specified. The CPT Code Manual 
definition of code 87900 is infectious agent drug susceptibility phenotype prediction using regularly updated 
genotypic bioinformatics.  
 
We find that CPT codes 87899 and 87900 are not supported in the medical record. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service September 
13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed for date of service January 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that supporting medical records were provided. The 
Plan denied your request. The Plan says the billed services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We find that the billed services are not supported in the medical record. Specifically, the enrollees date of birth 
listed on the claim does not match the enrollees date of birth provided in the medical records. It is noted that 
the Plan made multiple attempts to obtain additional information, without success. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for the drug testing billed for date of service January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hereditary Genetic Cardiac Test panel provided on October 10, 2022.

You asked the Plan to pay for the Hereditary Genetic Cardiac Test panel. You say that this testing was medically necessary and payable. The Plan denied your request. The Plan says criteria for coverage are not met.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, the Hereditary Genetic Cardiac Test panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Hereditary Genetic Cardiac Test panel provided on October 10, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alignable system and advanced foot. 
 
You asked the Plan to pre-approve alignable system and advanced foot identified with codes L5920, L5981, 
and L5986). You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthesis additions are only covered for certain 
indications. 
 
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 alignable system and advanced foot. 
Our reviewer says that the documentation does not support that the requested items are medically reasonable or 
necessary. Our physician reviewer found the enrollee's current prosthesis is almost two years old. The socket 
fits loose with multiple ply socks. The requested flex-walk system exceeds the enrollee's medical needs and is 
not medically necessary. The documentation does not support that the enrollee's currently alignable system is 
damaged or is unable to be used with the approved socket. Therefore, the enrollee does not meet criteria for the 
requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of alignable system and advanced foot have not been met. Therefore, we decided 
that the Plan does not have to pre-approve alignable system and advanced foot.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is medically necessary. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide CPAP or 
BiPAP therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
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. The Plan denied your request. The Plan says the enrollee does not 
meet all the required criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dermal-fat-fascia graft (15570). 
 
You asked the Plan to pre-approve the graft. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of dermal-fat-fascia graft for use in 
laminectomy surgery have not been demonstrated in the peer-reviewed literature. The Plan states that more 
research is needed to show safety and efficacy of the procedure. 
 
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 graft. 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 clinical need for dermal fat fascia graft in this routine spinal stenosis case. 
 
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 graft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the dermal-fat-fascia graft (15570).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing billed with code 83789 for August 18, 
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. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, we find that the testing described by the billed code 
is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan 
does not have to pay for the validity testing billed with code 83789 for August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 15, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on September 15, 2022.
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 need aggressive physical therapy so you can be 
released home and return to normal activities. The Plan denied your request. The Plan says your records do not 
show that your rehabilitation needs are complex and that you need to be seen 3 times per week for evaluation 
of functional and medical goals and progress. 
 
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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 3-
5 targets (87631) provided on July 16, 2021. 
 
You asked the Plan to pay for infectious agent detection by nucleic acid (DNA or RNA); 3-5 targets. You say 
that the claim was filed timely. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for infectious agent detection by nucleic acid (DNA or RNA); 3-5 targets was 
not filed until November 23, 2022. This means that more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for infectious agent 
detection by nucleic acid (DNA or RNA); 3-5 targets (87631) provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D3428) for tooth #8, and biologic 
materials to aid in soft and osseous tissue regeneration (D3431) for the upper right quadrant. 
 
You asked the Plan to pre-approve a bone graft (D3428) for tooth #8, and biologic materials to aid in soft and 
osseous tissue regeneration (D3431) for the upper right quadrant. You say that you have attached supporting 
records showing the problem and the reason for this procedure. The Plan denied your request. The Plan says 
bone grafts (D3428) and biologic materials to aid in soft and osseous tissue regeneration (D3431) are not 
included as covered procedures in your EOC. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone graft (D3428) for tooth #8, and biologic materials to aid in soft and osseous tissue regeneration (D3431) 
for the upper right quadrant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided on July 05, 2022. 
 
You asked the Plan to pay for moderate sedation services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for moderate sedation 
services provided on July 05, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve a portable wheelchair ramp. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a portable wheelchair ramp (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99306 billed for date of service 
January 26, 2022. 
 
You asked the Plan to pay for procedure codes 99223 and 99306. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met because the 
available 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. 
 
We find that CPT codes 99223 and 99306 are not supported in the medical record. Specifically, records for date of service January 26, 2022, have not been made available for review. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99223 and 99306 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99223 and 99306 billed for date of service 
January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that testing causes pain in the enrollee's fingers. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).