Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after April 24, 
2022. 
 
You asked the Plan to pre-approve SNF care. You say that you would like additional SNF care covered because 
you will have nowhere to go if you are discharged. The Plan denied your request. The Plan says that continued 
SNF care is not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before April 24, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after April 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve prosthetic equipment. You say that this equipment is medically necessary. 
The Plan denied your request. The Plan says there are in-network providers available to meet your prosthetic 
needs. 
 
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 
prosthetic equipment to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical collar (L0180), provided on June 9, 2021. 
 
You asked the Plan to pay for the cervical collar. You say that the item is medically necessary. The Plan denied 
your request. The Plan says an invalid physician order was submitted, the treating physician confirmed they did 
not order this item. 
 
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  physician order. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the cervical collar (L0180), provided on June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total hip arthroplasty (27130). 
 You asked the Plan to pre-approve a right total hip arthroplasty. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue is not medically necessary as the 
enrollee does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a right total hip arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. Formal imaging studies are not 
provided for review to corroborate the pathology. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 right total hip arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a right total hip arthroplasty (27130).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on 
October 10, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says that an invalid physician order was submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan covers what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM supplies have been met. Therefore, we decided that the Plan has to pay for the 
continuous glucose monitor (CGM) supplies (K0553), provided on October 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinical decision support services provided from June 21, 
2021, to June 24, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
are information only. 
 
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 G1004 is clinical decision support mechanism national 
decision support company, as defined by the Medicare appropriate use criteria program. 
 
 
 We find that CPT code G1004 is not paid by Medicare when submitted on outpatient claims. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the clinical decision support services provided from June 21, 2021, to June 24, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted molecular pathology procedure, GeneSight 
Psychotropic test (81479) provided October 12, 2021. 
 
You asked the Plan to pre-approve GeneSight Psychotropic test. You say that you request reconsideration of 
the original determination and cover the GeneSight Psychotropic test as medically necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. The claim did not include the Z code as 
required. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of GeneSigt Psychotropic test have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the unlisted molecular pathology procedure, GeneSight Psychotropic test (81479) provided 
October 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two home health aide (HHA) visits (G0156 x2). 
 
You asked the Plan to pre-approve the HHA visits. The Plan denied your request. The Plan says the record 
shows that you have caregiver(s) who help with your daily living activities which include bathing, dressing, 
toileting, grooming, cleaning, and meal preparation. The Plan also says that this information does not support 
the need for a home health aide to make visits. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 HHA visits. Our reviewer says that 
the HHA services are not medically reasonable and necessary. Our physician reviewer found you do not have 
documented skilled needs.  Our reviewer also found that as such, commiserate HHA services are not required 
to assist in the treatment of illness 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 HHA visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve two home health aide (HHA) visits (G0156 x2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
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 pre-approve a PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the records did not support that the member 
met diagnostic criteria for both AD and FTD at this time.  
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Retacrit or Procrit, 
for at least 2 months. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
support that Retacrit or Procrit have been tried and failed by the enrollee. The reviewer found that the 
documentation does not support that Retacrit, or Procrit would likely be less effective, and/or would likely have 
adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not 
been 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 17, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that your wife had fallen, and she was taken to 
the hospital for emergency care. The Plan denied your request. The Plan says no separate payment is made for 
code 99053 because payment for this code is bundled into payment already made for code 99285 billed on the 
same date of service. 
 
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 99053 is a column II code to column I code 99285. 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 99053 billed for date of service October 17, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) device 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the CPAP device. You say that you do not wish to use the Plan's contracted 
providers. The Plan denied your request. The Plan says there are in-network providers available to meet your 
medical requirements. 
 
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 
the continuous positive airway pressure (CPAP) device to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a laparoscopic nephrectomy. 
 
You asked the Plan to pre-approve a laparoscopic nephrectomy. You say that you would like reconsideration 
because the requested procedure is medically necessary. The Plan denied your request. The Plan says that the 
enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a laparoscopic nephrectomy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the tumor is enlarging. The tumor is mid-pole and partial nephrectomy would be 
more difficult and riskier than nephrectomy. Also, the patient has normal renal function and a normal right 
kidney, so a partial nephrectomy is unnecessary. 
 
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 laparoscopic nephrectomy have been met. Therefore, we decided that the Plan 
has to pre-approve a laparoscopic nephrectomy.  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a three dimensional (3D) rendering with interpretation and 
reporting (76377). 
 
You asked the Plan to pre-approve a 3D rendering with interpretation and reporting. The Plan denied your 
request. The Plan says that the 3D rendering with interpretation and reporting is not medically necessary. The 
Plan also says that you were approved for a cerebral angiogram without 3D rendering. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a 3D rendering with interpretation and 
reporting. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the plan here is to do a catheter direct cerebral angiogram, 
not a computed tomography (CT) or magnetic resonance imaging (MRI) angio. The reason for the requested 
3D rendering on the angio is to obtain maximum anatomic detail with the plan including possible embolization 
as surgery has been deemed inadvisable. Our reviewer found that the denial seems to be considering 
unnecessary 3D rendering on MRI or CT, but the necessity of 3D rendering for a catheter direct angio is 
present especially given the plan to consider re-embolization.  Our physician reviewer also found that the 3D 
rendering should be approved as part of the cerebral angiogram which is planned. 
 
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 3D rendering with interpretation and reporting have been met. Therefore, we 
decided that the Plan has to pre-approve a three dimensional (3D) rendering with interpretation and reporting 
(76377).  
 
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 the continuous positive airway pressure (CPAP) device 
(E0601), provided on August 18, 2021. 
 
You asked the Plan to pay for the CPAP device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item was obtained through a provider not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device (E0601), provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77435 billed for date of service November 
15, 2021. 
 
You asked the Plan to pay for procedure code 77435. You say that you have provided medical records to 
support the billing. The Plan denied your request. The Plan says payment for code 77435 is bundled into payment already made for code 77301-26 billed for the same date of service by another doctor in the same 
practice. 
 
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 77435 
is a column II code to column I code 77301-26. 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 77435 billed for date of service November 15, 
2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on 
September 10, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says that a valid physician order was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM supplies have been met. Specifically, there was a valid physician order submitted. 
Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on September 10, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion 
for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of a minimally invasive 
percutaneous sacroiliac (SI) fusion in the setting of bilateral SI joint pain and multilevel lumbar spinal stenosis 
has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding diagnostic imaging studies corroborating sacroiliac pathology. The x-
rays of the pelvis stated sacroiliac joints are unremarkable. Additionally, multiple other plausible pain 
generators including at the lumbosacral spine are evident. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion for the enrollee.