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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary to improve the 
enrollee's strength, mobility and activity tolerance. The Plan denied your request. The Plan says the services are 
not medically necessary at this time. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented nursing or skilled therapy needs that are 
required to prevent deterioration of their condition.  The enrollee's care needs can be provided in 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation (A0100). 
 
You asked the Plan to pre-approve additional routine transportation. You say that you receive dialysis three 
times a week and without transportation, it can be life-threatening. You do not have any other means of 
transportation. The Plan denied your request. The Plan says you receive up to 20 one-way trips per year. You 
have already completed 20 trips; therefore, you have exhausted your transportation benefit for 2023. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergent routine transportation (A0100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint Peripheral Nerve Stimulator (64555). 
 
You asked the Plan to pre-approve the Peripheral Nerve Stimulator. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the Peripheral Nerve Stimulator. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective or safe treatment for the noted pathology of chronic left knee pain. Further 
studies are needed to corroborate that this device is as effective or better than standard treatments. 
 
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 Peripheral Nerve Stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Sprint Peripheral Nerve Stimulator (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a home ventilator is not medically necessary. You were hospitalized with congestive heart 
failure (CHF), pulmonary edema, and pleural effusions. Some notes mention pneumonia. There is no diagnosis 
of chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, or neuromuscular disease. You 
were described as somnolent. Arterial blood gas (ABG) was consistent with combined respiratory acidosis and 
metabolic alkalosis. You may benefit from bilevel positive airway pressure (BiPAP) during sleep. This has not 
been tried as an outpatient. You do not have a diagnosis for which Medicare covers a home ventilator, and 
Medicare does not cover a ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation service (code 99153) provided on July 1, 
2022. 
 
You asked the Plan to pay for code 99153. You say that you are appealing this denial. The Plan denied your 
request. The Plan says this code is a technical component only code and should be reported by a hospital 
setting. 
 
The Plan must follow Medicare rules. Medicare rules say that code 99153 is a Technical Component only code.  
 
We looked at the file and Medicare rules. This code represents the technical component of the service only, so 
should not be billed on a professional service claim. Based on this information, we decided that Medicare rules 
for coverage of code 99153 have not been met. Therefore, we decided that the Plan does not have to pay for 
moderate sedation service (code 99153) provided on July 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail oral bisphosphonate first. 
 
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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the record indicates that the enrollee has 
age related osteoporosis without osteoporotic fracture. The requested medication is a new start. The provided 
records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this procedure is investigational and is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found documentation is not supportive of the spinal vertebral bodies as being the overwhelming 
primary generators of the enrollees chronic persistent pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44120 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 44120. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 44120 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 44120 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 44120 billed for date of service September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that that this is medically necessary.The Plan 
denied your request. The Plan says you do not qualify for this wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that that there 
is insufficient documentation regarding your level of mobility and function and need for a power mobility 
device. There is also insufficient documentation regarding your motor strength and range of motion. Lastly, a 
PMD evaluation is required to determine if you can safely use the requested device, and that your home is 
accessible for use of the wheelchair.  
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 19, 2022 to 
March 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis of sepsis, unspecified organism. 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that in this case, there was no clinical or laboratory evidence of sepsis. 
The review has determined that the documentation did not support A41.9 - sepsis, unspecified organism.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 19, 2022 to March 25, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex procedure is experimental. More research is needed to demonstrate 
its safety and effectiveness. 
 
 
  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0481) provided on September 8, 2022. 
 
You asked the Plan to pay for drug test code G0481. You say that you are appealing with supporting records 
referencing 9 approved drug classes. The Plan denied your request. The Plan says that the documentation does 
not support 8 to 14 drug classes, only 5 drug classes were tested. 
 
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 G0481 is drug test(s), definitive; qualitative and quantitative, all sources, includes specimen validity 
testing, per day; 8 to 14 drug classes, including metabolites if performed. 
 
We find that CPT code G0481 is supported in the medical record. Specifically, the documentation submitted 
includes definitive drug testing results for 9 drug classes. Based on this information, we decided that Medicare 
rules for coverage of drug test code G0481 have been met. Therefore, we decided that the Plan has to pay for 
definitive drug testing (G0481) provided on September 8, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Germline Prostate Panel. 
 
You asked the Plan to pre-approve Germline Prostate Panel. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 Germline Prostate Panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Germline Prostate Panel is not medically necessary in this case. The records show 
that the enrollee has had no evidence of disease since 2017 and the results of this testing would not change 
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 Germline Prostate Panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Germline Prostate Panel.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive panel (procedure codes 80307 and G0483) 
provided to the enrollee on June 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not specifically identify what tests are included in the comprehensive panel as 
noted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. Our 
physician reviewer found that the submitted medical records do not contain sufficient detail to support the 
billed charges. The review indicates that the records did not adequately show exactly what tests were done in 
this case.. Therefore, we decided that the Plan does not have to pay for a comprehensive panel (procedure 
codes 80307 and G0483) provided to the enrollee on June 9, 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 the enrollee would benefit from rehabilitation 
services to help them become more stronger before returning home independently. The Plan denied your 
request. The Plan says the enrollee can receive the skilled therapies needed at home or at a skilled nursing 
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 there are no acute rehab skilled nursing needs identified or documented. While the 
enrollee may benefit from physical or occupational therapy, the enrollee's rehab needs can be provided in a 
lower intensity and alternate setting such as in a skilled nursing 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99245) with an oncologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have a rare form of cancer that needs 
immediate attention. You have possibly months to a year to live. You are requesting a second opinion 
consultation with the requested provider. Any delay in services would be detrimental to health. The Plan denied 
your request. The Plan says you must use network providers to get your medical care and services. There are 
additional in-network providers available for second opinions. 
 
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 
an office visit (99245) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment under special supplemental 
benefits for the chronically ill (SSBCI). 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not qualify for this benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we have confirmed that you do not have one of the 
eligible conditions listed in the Evidence of Coverage. Our physician reviewer found that the documentation 
does not support that the enrollee has had two or more inpatient admissions in the last 60 days, or three or more 
emergency room visits in the last 60 days. The documentation does not support a high risk for unplanned 
hospitalization in the next 60 days. The enrollee has multiple medical conditions, including asthma and 
depression. However, the progress note documentation does not indicate that any of these diagnoses are 
currently life-threatening or significantly limiting to the overall health or function of the patient. Therefore, we 
decided that the Plan does not have to pre-approve durable medical equipment under special supplemental 
benefits for the chronically ill (SSBCI).