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

 
We decided that the Plan does not have to provide a positron emission tomography (PET) scan. 
 
You asked the Plan to provide a positron emission tomography (PET) scan. You say that the services requested 
are medically necessary. The Plan denied your request. The Plan says the National Coverage Determination 
(NCD) criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 provide Positron emission tomography (PET) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that while the 
records mention short term memory loss and mild cognitive decline no quantification of same is included.  
Importantly CMS requires a differential diagnosis of fronto-temporal dysplasia and Alzheimer's disease for 
PET/CT to be covered and no such differential is present in this case.  Absent this information the CMS criteria 
for PET/CT are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Positron emission tomography (PET) scan have not been met. Therefore, we 
decided that the Plan does not have to provide a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 20, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from an acute rehabilitation 
facility stay. The Plan denied your request. The Plan says the documentation does not indicate that there are 
comorbidities that would require close supervision by a rehabilitation physician. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you continue to have a need for skilled therapy; however, the documentation 
does not support that the criteria for admission to an acute inpatient rehabilitation facility have been met. You 
can receive further services 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated 
technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or 
pharmacologic) and/or redistribution and/or rest reinjection (78452). 
 
You asked the Plan to pay for the pharmacological nuclear stress test. You say that s this test is required to 
have surgery done. The Plan denied your request. The Plan says under Medicare guidelines, your request is not 
medically necessary because your records do not show that your electrocardiogram is nondiagnostic nor you 
have any medical condition which limits your walking on treadmill, nor have you had any previous treadmill 
exercise stress test.  
 
The Plan follows Medicare rules. Medicare rules say that the pharmacological nuclear stress test is covered 
when 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 pharmacological nuclear stress test. Our 
reviewer says that the pharmacological nuclear stress test is not medically reasonable and necessary. Our 
physician reviewer found the enrollee is being cleared for planned surgery. There is no documentation that the 
electrocardiogram shows an uninterpretable pattern. There is no evidence provided that would support the need 
for radionuclide stress testing. In summary, there is insufficient documentation to support the medical necessity 
for the requested cardiac stress testing in this enrollees 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 pharmacological nuclear stress test have not been met. Therefore, we 
decided that the Plan does not have to pay for myocardial perfusion imaging, tomographic (SPECT) (including 
attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, 
additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) 
and/or redistribution and/or rest reinjection (78452).
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 enrollee would benefit from this higher level of 
care. A letter received from the enrollee argues that more intensive therapy is needed to prevent prolonged 
disability in the right knee. The Plan denied your request. The Plan says the criteria for IRF care have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for septic arthritis of the foot. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorperazine 10mg tablets. 
 
You asked the Plan to pre-approve Prochlorperazine. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit as it is 
not being used as a full replacement for IV anti-emetics. 
 
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 Prochlorperazine 10mg 
tablets.  
 Benefits for Prochlorperazine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmological services to be provided by the 
requested provider. 
 
You asked the Plan to pre-approve ophthalmological services, You say that the services are medically 
necessary. The Plan denied your request. The Plan says you do not need higher level of care. 
 
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 ophthalmological services to be 
provided by the requested provider. Our reviewer says that the ophthalmological services to be provided by the 
requested provider are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that you require a vision examination and cataract follow-up. The 
Plan has indicated that these services are available from a non-tertiary care provider. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
The elements of the coverage criteria 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 ophthalmological services to be provided by the requested provider have not 
been met. Therefore, we decided that the Plan does not have to pre-approve ophthalmological services to be 
provided by the requested provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 8, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you had to be transferred to 
another hospital because they couldn't help you at the first one, so you shouldn't have to pay for that. The Plan 
denied your request. The Plan says the copayment applied is correct. 
 
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 $90 
copayment per one-way trip for Medicare covered ambulance services.  
 
 
 
 You have been asked to pay $90 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 transport 
provided on March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab, radiology and surgery services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve out-of-network care. You say that these services are medically necessary, 
and you trust this provider and facility. The Plan denied your request. The Plan says they agree these services 
are necessary; however, this treatment can be performed by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
lab, radiology and surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the pelvis. 
 
You asked the Plan to pre-approve an MRI of the pelvis. You say that an MRI of the pelvis is medically 
necessary. The Plan denied your request. The Plan says an MRI of the pelvis does not meet the Medicare 
coverage criteria. 
 
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. Our reviewer says 
that an MRI of the pelvis is not medically necessary. Our physician reviewer found that the record indicates 
that you have non-traumatic coccydynia. The record indicates that you also have lumbar radiculopathy. 
Physical examination demonstrates point tenderness of the coccyx. No plain films are reported to have been 
performed and conservative treatment has not yet been attempted. The requested service is not medically 
necessary and reasonable for the diagnosis and treatment for your clinical condition at this time. The elements 
of the coverage criteria 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 an MRI of the pelvis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a varicose vein treatment procedure (36471, 36470). 
 
You asked the Plan to pre-approve the varicose vein treatment procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this varicose vein treatment is only covered in the 
absence of significant peripheral arterial diseases. 
 
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 varicose vein treatment procedure. 
Our reviewer says that this procedure is not medically necessary. Our physician reviewer found the enrollee has 
severe narrowing of the arteries in the right leg from the information and imaging reviewed. Per Medicare 
rules, varicose vein treatment cannot be approved if there is evidence of peripheral arterial disease. 
 
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 varicose vein treatment procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a varicose vein treatment procedure (36471, 36470).
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 enrollee would benefit from IRF care. The Plan 
denied your request. The Plan says the enrollee is weak from a recent illness, their therapy needs are not 
complex in nature, and can be provided at a lower level of care. The Plan also says the enrollee does not require 
more than one (1) intensive therapy at least three (3) hours per day, five (5) days per week. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this patient 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on March 
28, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you thought there was no charge for 
a colonoscopy. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $290 
copayment for each Medicare covered outpatient hospital facility visit. 
 You have been asked to pay $290 copayment for colonoscopy. Diagnostic colonoscopys fall within the 
Outpatient Surgery Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 diagnostic colonoscopy 
provided on March 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the home health services. You say that the home health services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records do not show any 
skilled nursing or therapy needs. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your needs can be 
met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you continue to have a need for skilled therapy; however, the documentation 
does not support that you have met criteria for admission to an IRF. You can receive further services 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen. 
 
You asked the Plan to pre-approve Privigen. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Privigen.  
 
Benefits for Privigen may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.