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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was 
admitted with renal insufficiency in the setting of cirrhosis and worsening ascites. The record indicates that the 
enrollee still has hyponatremia and refractory ascites that requires further paracentesis. The record indicates 
that the enrollee requires ongoing acute care services. 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 she is 
not currently receiving but that would be available at the LTACH facility. The LTACH services are not 
reasonable or 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
after April 30, 2022. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care remains medically 
reasonable and necessary. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a 
lower level of care (ex. home, long term care facility). 
 
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 SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after April 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar laminectomy. 
 
You asked the Plan to pre-approve a lumbar laminectomy.. You say that this surgery service is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
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 lumbar laminectomy.. 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 documentation of 6 weeks of physical therapy for lower back pain. In this 
case, surgery is not needed 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 lumbar laminectomy. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar laminectomy.
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 you do not need an 
intensive team for 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 physician reviewer found 
that you were admitted to the acute care hospital for congestive heart failure and renal failure. Your medical 
problems are stable. The complexity of your 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: 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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules 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 that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No rehab nursing needs identified or documented 
in the record. The enrollee's does not need 3 hours a day five days a week of IRF therapies with 
interdisciplinary management and his needs can be met in an alternate and lower setting such as in a skilled 
nursing facility. She needs routine physical therapy and occupational therapy. IRF admission is not medically 
necessary based on medical stability, lack of medical complexity, and lack of rehab nursing needs. Document 
does not support the necessity for admission to 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 receiver device. 
 
You asked the Plan to pre-approve the Dexcom G6 receiver device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the member does not use insulin with at least three 
daily injections. 
 
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 
the Dexcom G6 receiver device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Dexcom G6 receiver device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered on July 25, 2021. 
 
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 procedure code 99053 is not separately payable.  
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 code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. 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 pay for the medical 
services rendered on July 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spectrometry testing (83789) provided on October 27, 2021. 
 
You asked the Plan to pay for spectrometry testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this cannot be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens used for drug testing shall not separately bill the validity testing. For example, if a laboratory 
performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine 
specimen is not adulterated, this testing is not separately billed. 
We find that CPT code 83789 is not supported in the medical record. Specifically, the records show that this 
testing was performed as validity testing for the specimen used for drug testing. Based on this information, we 
decided that Medicare rules for coverage of spectrometry testing have not been met. Therefore, we decided that 
the Plan does not have to pay for spectrometry testing (83789) provided on October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device is considered investigational under 
Medicare guidelines and is not a covered benefit. 
 
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 CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contractual agreement in place which indicates that the CPT codes billed are included in the dialysis 
rate. The Plan denied your request. The Plan says laboratory testing related to treatment of end-stage renal 
disease is bundled into dialysis services and is not separately reimbursable. 
 
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 laboratory services provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT image capture (D0381) provided by a 
participating provider on November 2, 2021. 
 
You asked the Plan to pay for a cone beam CT image capture. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says D0381 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for a cone 
beam CT image capture (D0381) provided by a participating provider on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), intraoral - 
periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image 
(D0230) provided December 30, 2021. 
 
You asked the Plan to pay for the panoramic x-ray and periapical x-rays. You say that you feel the services 
were not covered because of the holiday weekend. The Plan denied your request. The Plan says these services 
are not covered under your benefits. 
 
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 pay for the panoramic radiographic image (D0330), intraoral - periapical first radiographic image (D0220), and intraoral - 
periapical each additional radiographic image (D0230) provided December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided on 
November 9, 2021, billed with code 83789. 
 
You asked the Plan to pay for the mass spectrometry testing. You say that this testing is medically necessary. 
The Plan denied your request. The Plan says the drug testing was approved for payment; however, code 83789 
is for validity testing which is not separately payable. 
 
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 the mass spectrometry testing 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 unspecified mass spectrometry testing provided on November 9, 
2021, billed with code 83789.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Bilateral Inguinal Hernia Repair (49520, 49505, 
49650, 49651, 49521, & 49507), to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Bilateral Inguinal Hernia Repair. You say that the service is medically 
necessary. The Plan denied your request. The Plan says there are in-network providers available to perform this 
service. 
 
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 Bilateral Inguinal Hernia Repair (49520, 49505, 49650, 49651, 49521, & 49507), 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 pre-approve custom foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the doctor requested this for feet deformity from 
enlarged bunions and poor weight distribution. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics (L3000).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy (J9228) and Opdivo (J9299). 
 
You asked the Plan to pre-approve Yervoy and Opdivo. You say that the requested treatment is necessary. The 
Plan denied your request. The Plan says the requested therapy is not medically necessary for the enrollee's 
condition. 
 
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 Yervoy and Opdivo. Our reviewer says 
that the requested drug regimen is not medically necessary. Our physician reviewer found that there are no 
actionable mutations, and status is PD-L1 0%. The documentation indicates that the enrollee has had disease 
progression while on pembrolizumab. There is no evidence that re-challenging with immunotherapy following 
progression on the same or a different regimen that entails the use of an immunotherapeutic agent is associated 
with any clinical benefit. The reviewer found that the requested use of Yervoy and Opdivo is not FDA-
approved for the enrollees diagnosis.  Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal (see appendix for list of CMS-approved journals). Therefore, the reviewer found that 
the requested drug regimen is not medically reasonable or 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 Yervoy and Opdivo have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy (J9228) and Opdivo (J9299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (T4535). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (T4535).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the service is medically necessary. The 
Plan denied your request. The Plan says you do not use insulin with at least three daily injections and require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results 
 
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 and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).