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

 
We decided that the Plan does not have to pre-approve a brain imaging, positron emission tomography (PET) 
scan; metabolic evaluation (78608). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Fluorodeoxyglucose (FDG) Positron Emission 
Tomography (PET) scan is considered reasonable and necessary in patients with a recent diagnosis of dementia 
and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimers 
Disease (AD) and Frontotemporal Dementia (FTD). 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that according to the medical 
records provided the enrollee has only been diagnosed with a mild cognitive impairment (MCI) with a 
suspicion of Alzheimers Disease. The records provided for review did not demonstrate that the enrollee 
otherwise met diagnostic criteria for both Alzheimers Disease (AD) and Frontotemporal Dementia (FTD) as 
required by Medicare rules for coverage of the requested imaging modality.  In as much, it cannot be independently determined that the requested service would meet the requirements for 
coverage 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a brain imaging, positron emission tomography (PET) scan; metabolic evaluation (78608).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on December 27, 2021, to 
December 29, 2021, 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 the 
claim was billed properly and should be paid. The Plan denied your request. The Plan says that documentation 
does not support the billed code. 
 
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 principal diagnosis code I26.92, described as saddle 
embolus of pulmonary artery without acute cor pulmonale. 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 
documentation does support the billed code. Our physician reviewer found the enrollee was a then, 72 -year-old 
female with a history of hypertension, asthma and melanoma who presented to the Emergency department on 
December 27, 2021, with shortness of breath. She was evaluated and found to have computed tomography 
chest evidence of saddle embolism. She was admitted to and received ecosonic endovascular system therapy. 
Her condition stabilized and improved, and she was discharged home when considered medically stable on 
12/29/2021. Saddle pulmonary embolism (SPE) is a rare type of acute pulmonary embolism (PE) that can lead 
to sudden hemodynamic collapse and death.  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on December 27, 2021, to December 29, 2021, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Orthovisc and Synvisc/Synvisc-One before it will 
approve Durolane. 
 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 Durolane. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Durolane. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Synvisc/Synvisc-One. The record 
does not show that these drugs would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Durolane.
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 home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the requested skilled nursing services meet Medicare 
criteria for coverage. Your wound is reported to be healed. Provided records do not document any acute or 
unstable medical conditions or changes in medication or treatment which would necessitate skilled nursing 
visits. Records document that you still drive, and records do not clearly document that you are home bound. 
Assisting with donning your compression stockings is not a skilled nursing service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
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 MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's brachial plexus condition or in widespread use for this enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 
   
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
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 need the care at a rehabilitation center after 
being discharged from the hospital. You say that you do not have any discharge plans if denied admission to an 
IRF. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your needs 
can be met at an alternate 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87798) provided on June 15, 
2022. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting the plan to reconsider the 
denied charges with the submitted supporting documentation. The Plan denied your request. The Plan says 
charges for or in connection with services or supplies that are, as determined, considered to be experimental or 
investigational are excluded from coverage under the enrollee's plan. 
 
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 87481, 87798 is not supported in the medical record. Specifically, there is no applicable 
CMS guidance for the enrollees or the providers geography. As such, the health plan has utilized a review of 
the medical literature in the absence of CMS policy. Based on this information, we decided that Medicare rules 
for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services (87481, 87798) provided on June 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the member requires an IRF admission. The Plan 
denied your request. The Plan says admission to acute rehabilitation is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are bed bound and has not been able to move for 
over 2 years, need assistance with bathing, and needs assistance with regaining mobility. The Plan denied your 
request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not been met, 
medically necessary care may be provided safely in a different 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 the complexity of enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery to be provided by an out-of-network 
(OON) surgeon. 
 
You asked the Plan to pre-approve the OON spinal surgeon. You say that you are in constant pain and need this 
surgery. The Plan denied your request. The Plan says you have been approved for this surgery; however, an in-
network surgeon must be chosen. 
 
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 file indicates that you have 
been seeing this OON provider without authorization from 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 spinal 
surgery to be provided by an out-of-network (OON) surgeon.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76441 billed for date of service November 
29, 2022. 
 
You asked the Plan to pay for procedure code 76441. You say that this should be paid for. 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 for the HCPCS/CPT code will be denied.  
In this case, the MUE for CPT code 76441 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76441 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76441 billed for date of 
service November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305, 88342, 88344) provided on 
October 24, 2022. 
 
You asked the Plan to pay for the pathology services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88305, 88342, and 88344 are not supported in the medical record. Specifically, N64.1 
is not a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage 
of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for 
pathology services (88305, 88342, 88344) provided on October 24, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for COVID infection and was transferred to skilled nursing 
on February 9, 2023. Medical problems are stable. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81240, 81241). 
 
You asked the Plan to pre-approve genetic testing. You say that you have been sick a lot and having some 
issues. Your oncologist would like for you to have this testing done to help get some answers. The Plan denied 
your request. The Plan says there is limited documentation to support the need for this genetic testing or how 
this information is needed to adequately assess risk or how the information will be used in the immediate care 
plan or will affect the treatments provided. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient evidence in the published peer-reviewed scientific literature to support 
coverage for genetic testing for inherited thrombophilia outside the pregnant women. Genetic testing for FVL 
and F2 G20210A is considered investigational for all other indications. However, Medicare may consider 
coverage for FVL and/or F2 genetic testing in unusual circumstances where testing will change clinical 
management. Denied claims can be appealed with supporting evidence of specific medical necessity. Only 
providers with evidence of formal training with board eligibility or certification in hematology/oncology, 
hematopathology or coagulation disorders at an accredited program satisfy reasonable and necessary criteria for 
these tests. There is broad consensus in the medical literature that MTHFR genotyping has no clinical utility in 
any clinical scenario. This testing is considered investigational and is not a Medicare benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81240, 81241).