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

 
We decided that the Plan does not have to pre-approve the nuclear stress test (75452). 
 
You asked the Plan to pre-approve the nuclear stress test. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Stress testing with cardiac imaging will be considered 
medically reasonable and necessary for the criteria listed 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 the nuclear stress test. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the patient has a history of 
obesity and hypertension, with no chest pains. The patients pre-test probability for an abnormal test is low and 
there is no documentation that his ECG shows an uninterpretable pattern. There is no evidence provided that 
would support the need for radionuclide stress testing. In summary, there is insufficient documentation to 
support the medical necessity for the requested cardiac stress testing in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the nuclear stress test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the nuclear stress test (75452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit on January 4, 2022. 
 
You asked the Plan to pay for a telehealth visit. You say that your copayment should be $0. The Plan denied 
your request. The Plan says you have been charged the correct copayment amount. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollee must pay a $25 copayment per visit to a specialist. Covered services include certain 
additional telehealth services, including those for consultation, diagnosis, or treatment by a participating 
provider. 
 
 
 
 
 You have been asked to pay a $25 copayment for the telehealth visit. The telehealth visit falls within the 
Physician/Practitioner services, including doctors office visits benefit category. The telehealth visit was not 
arranged through the telehealth services benefit. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided the Plan does not have to waive the copayment for the 
telehealth visit provided on January 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) scan of the 
neck. 
 
You asked the Plan to pre-approve MRA services. You say that this imaging service is medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for this imaging service have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MRA services. Our reviewer says that the requested MRA services are not medically reasonable and necessary. Our physician reviewer found that the 
reviewed documentation indicates that the enrollee had a bilateral duplex ultrasound test which showed 
minimal blockages and her provider doctor advised against the MRA test until evaluated by a vascular surgeon. 
The review has determined that the requested MRA is not medically reasonable and 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 MRA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance angiography (MRA) scan of the neck.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
home health services 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 oxygen equipment. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says there is no 
documentation of proper use. 
 The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
The file shows that a home oxygen concentrator and portable oxygen were requested. We looked at the file, 
and Medicare rules. The medical records we received were from September 2021. There are no recent medical 
records to show that oxygen is still needed for your condition. There are no recent medical records to show that 
coverage criteria have been met. Therefore, we decided that the Plan does not have to pre-approve oxygen 
equipment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve absolute quantitation of myocardial blood flow 
(AQMBF), positron emission tomography (PET), rest and pharmacologic stress (78434). 
 You asked the Plan to pre-approve absolute quantitation of myocardial blood flow, positron emission 
tomography, rest and pharmacologic stress. 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. 
 
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 absolute quantitation of myocardial 
blood flow, positron emission tomography, rest and pharmacologic stress. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found other modalities of stress testing have not been performed in this enrollee. Guidelines do not support the 
use of cardiac PET imaging in this role. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of absolute quantitation of myocardial blood flow, positron emission tomography, 
rest and pharmacologic stress have not been met. Therefore, we decided that the Plan does not have to pre-
approve absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest 
and pharmacologic stress (78434).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you 
have not had a recent MRI at that part of the spine. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
The file shows that one level of blocks was approved by the Plan. 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 requested additional level. Our physician reviewer found that you have chronic neck 
and back pain. You take Fentanyl patches, Tizanidine and Lyrica. You have done a home exercise program. 
You had medial branch blocks which gave her 60% pain relief for greater than 6 months. The request is to 
repeat the blocks. The request exceeds the utilization criteria. Therefore, the request for an additional level is 
deemed 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological medical examination (92014) and 
refraction (92015) provided on November 18, 2021. 
 
You asked the Plan to pay for the ophthalmological medical examination and refraction. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says codes 
92014 and 92015 are not covered by the Plan because the provider is outside of the enrollee's network of 
providers. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided by a network provider. 
 
We looked at the file and the Plan's rules. The file shows that the vision services were provided by an out-of-
network provider. Based on this information, we decided that the Plan's rules for coverage of the 
ophthalmological medical examination and refraction have not been met. Therefore, we decided that the Plan 
does not have to pay for the ophthalmological medical examination (92014) and refraction (92015) provided on 
November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 11, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare 
guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until October 28, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on September 11, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) care provided on 
November 13, 2021, through December 7, 2021. 
 You asked the Plan to pay for the SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee did not meet Medicare criteria for 
coverage. 
 
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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the member did not have any parental 
medications, complex wound care or nutrition given via a feeding tube.  The member received skilled care and 
improved; however, his/her functional improvement had plateaued by November 8, 2021 and she did not 
require any further inpatient skilled rehab services. The members function was at or near her prior level of 
function and she could be discharged to a lower level of care for further services. As of November 8, 2021, the 
member required custodial 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the Skilled Nursing Facility (SNF) care provided on November 13, 2021, through December 7, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural injection services. 
 
You asked the Plan to pre-approve epidural injection services. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says there is no objective evidence of 
radiculopathy on the exam that corroborates imaging findings. 
 
The Plan follows Medicare rules. Medicare rules say that epidural injection services are subject to the criteria 
listed 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 epidural injection services. Our 
reviewer says that the requested injection services are not medically reasonable and necessary. Our physician 
reviewer found this 71-year-old woman has chronic low back pain. On physical exam, no signs of lumbar 
radiculopathy are documented. On magnetic resonance imaging scan, multi-level spondylosis is documented 
but there is no documentation of disc displacement causing foramenal or canal stenosis. There is no indication for an Epidural Steroid Injection. The request 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 epidural injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural injection services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT guidance for needle placement (eg, biopsy, 
aspiration, injection, localization device), radiological supervision and interpretation (CPT code 77012). 
 
You asked the Plan to pre-approve the CT scan. You say that you are requesting an appeal for the computed 
tomography guidance for needle placement for the possibility of lymphoplasmacytic lymphoma. You state the 
enrollee's bone marrow is not normal and they need to have a biopsy to find out why. The Plan denied your 
request. The Plan says nothing in the medical record supports the medical necessity of imaging for this 
procedure and it is not the standard of care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's bone marrow is not normal and need to do a biopsy to find out why. There is no 
requirement found in the literature for CT guided needle placement to be performed in conjunction with the bone marrow biopsy. There is no documentation in the clinical records provided to support any extenuating 
circumstances that would require CT guided needle placement for the bone marrow biopsy. The review has 
determined that the items/services at issue in this case are not medically reasonable and 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT guidance for needle placement (eg, biopsy, aspiration, injection, localization device), 
radiological supervision and interpretation (CPT code 77012).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fifteen (15) fractions of IMRT. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is no current research showing that the enrollee's type of cancer responds better to 
the requested type of treatment than the type of treatment the Plan can approve. The Plan states this type of 
treatment is called 3D-CRT (three-dimensional, conformal radiation therapy). The Plan states it matches the 
target and uses beams of energy to damage cancer cells to stop their growth and 3D-CRT would be approved if 
requested. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the need for IMRT is not adequately justified in the case records. Our physician reviewers 
decision is unfavorable, as they believe that 3D radiation versus IMRT would be within accepted standards of 
care when there are no plausible or compelling dosimetric measures justifying the need for IMRT. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve fifteen (15) fractions of IMRT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically reasonable and necessary 
for your condition. 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 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose 
monitor (CGM).