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

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
September 30, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that you are being billed two copayments. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for other Medicare-covered outpatient diagnostic procedures and tests.  
 
 You have been asked to pay $15.61, which is less than the standard $25 copayment for the EKG. This 
item/service falls within the outpatient diagnostic tests and therapeutic services benefit category. 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 that the Plan 
does not have to waive the copayment for the electrocardiogram (EKG) provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated wheelchair seat cushion (E2609) 
and a custom fabricated wheelchair back cushion (E2617). 
 
You asked the Plan to pre-approve the DME. You say that you believe the enrollee would benefit from custom 
seating due to the enrollee's deformities. The Plan denied your request. The Plan says the custom seating 
options are not felt required to meet the enrollee's medical needs. 
 
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 DME. Our physician reviewer 
found the documentation indicates the enrollee can be effectively positioned with the prefabricated skin 
protection/pressure relief seat cushion and back cushion. The requested custom seating options are not 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a custom fabricated wheelchair seat cushion (E2609) and a custom fabricated wheelchair back 
cushion (E2617).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services coded as 88184, 88185, 88189, 88368 and 
88377 provided April 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please find the attached medical records and 
clinicals along with the waiver of liability. The Plan denied your request. The Plan says that the information 
requested from the billing/rendering provider was not provided or was not provided timely or was insufficient 
or incomplete. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that it is crucial to understand that flow cytometry analysis is often used in conjunction with 
other descriptive tests such as morphologic examination. Pathologists review the cellular morphology of the 
specimens. Often, hematologic neoplasms depict specific morphologic changes, and flow cytometry provides 
greater specificity. Flow cytometry often can detect recurrence of cancer before morphologic changes are 
detected. In this case, the enrollee has a diagnosis of leucoerythroblastic anemia and thrombocytosis. The 
results of the testing demonstrated a Myeloid neoplasm with 5% circulating blasts and STAG2 (Stromal 
Antigen 2) and SF3B1 (Splicing factor 3B subunit 1) mutations. The review has determined that the 
items/services at issue in this case were 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 laboratory services have been met. Therefore, we decided that the Plan has 
to pay for the laboratory services coded as 88184, 88185, 88189, 88368 and 88377 provided April 7, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy. 
 
You asked the Plan to pre-approve the therapy services. The Plan denied your request. The Plan says physical 
therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the documentation does not include an updated physical exam and 
does not detail your current functional status. There is no clear documentation regarding your functional 
mobility or what type of goals you have regarding the requested physical therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for computed tomography of the head, brain, thorax, cervical spine, 
abdomen, and pelvis, plus x-ray of the pelvis, knee, tibia and fibula, ankle rendered on June 18, 2022, and June 
19, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that more details are needed to determine if the charges are eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found that the enrollee 
sustained a serious motor vehicle accident and was brought to the emergency department (ED) having lost 
consciousness. When awake, the patient complained of multiple sites of pain. The various CT scans are typical 
scans done after serious trauma where the patient has lost consciousness. The various x-rays were done at the 
time of ED admission and were also typical exams in a patient with somatic complaints after such an accident. 
All of these exams were reasonable and necessary in a patient who has had trauma and loss of consciousness. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
computed tomography of the head, brain, thorax, cervical spine, abdomen, and pelvis, plus x-ray of the pelvis, 
knee, tibia and fibula, ankle rendered on June 18, 2022, and June 19, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires max assistance and is at high 
risk for falling. The Plan denied your request. The Plan says the request 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 that the enrollees 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the CPAP failed in the home and in the 
hospital. The Plan denied your request. The Plan says the records do not show that the enrollee has failed 
management with BiPap. The ventilator prescription indicates the device will be used exclusively in a BiPap 
setting. The request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure and chronic obstructive pulmonary disease. Provided records document that the 
home ventilator is being requested for use in targeted tidal volume - volume assured pressure support (TTV-
VAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with average volume 
assured pressure support (AVAPS) and a back-up rate. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 8, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not know that you had to go to the hospital. You also say that you were told you weren't having a heart attack 
so you did not feel the need to go to the hospital. The Plan denied your request. The Plan says these services 
are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 8, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI) services. 
 
You asked the Plan to pre-approve the SSBCI services. You say that the medical records provided support the 
need for SSBCI care. The Plan denied your request. The Plan says there is no documentation supporting that 
the criteria for coverage have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the provided documentation did not 
sufficiently support medical necessity. Although the enrollee has a few chronic, stable conditions being 
managed appropriately by the treating physician, the enrollee does not have an active diagnosis for one or more 
qualifying comorbid and medically complex conditions. The enrollees conditions are not life-threatening or 
significantly limiting the overall health or function of the enrollee. The enrollee does not require intensive care 
management and is not at a high risk for hospitalization based on the provided documentation.   
We looked at this physicians review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SSBCI 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. Therefore, we decided that 
the Plan does not have to pre-approve special supplemental benefit for the chronically ill (SSBCI) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution 
injection (62264). 
 
You asked the Plan to pre-approve an injection. You say that your doctor recommended the surgery so you can 
have full strength and mobility in your right leg and to decrease your risk of falling. The Plan denied your 
request. The Plan says the requested service is not medically reasonable or 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 an injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation does not show that the enrollee has any indications for this procedure. 
Therefore, the reviewer found that the requested injection 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 an injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous lysis of epidural adhesions using solution injection (62264).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires skilled nursing care for 
medication management and assistance with short-term physical rehabilitation. The Plan denied your request. 
The Plan says that the enrollee requires skilled nursing care for medication management and assistance with 
short-term physical rehabilitation. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is a male hospitalized for peripheral artery disease. The clinical 
documentation shows that the enrollee has had a clinical and functional status change requiring skilled nursing 
and therapy assessment. The evaluating therapists feel that daily skilled therapy is needed, as the enrollee 
required standby assist for ambulation, but was still requiring minimal assistance for transfers and bed mobility, 
as well as stair ability. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: 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 skilled nursing facility care would not be able to 
provide the high level of medical services the member requires and would prolong their stay in an institution 
opposed to going home with home health care or outpatient services. The Plan denied your request. The Plan 
says the necessary services can be provided 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 member is a 71-year-old male with a past medical history including chronic pain 
syndrome, chronic kidney disease and cardiac disease who was admitted to the hospital due to confusion and a 
change in mental status. The most recent therapy notes indicate that the member requires minimal assistance to 
ambulate short distances and can transfer without hands on assistance. 
 
In this case, the complexity of the members nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is no indication that the member would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain his functional status.  
 
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 pay for procedure code 64421 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 64421. The Plan denied your request. The Plan says procedure 
code 64421 is an add on code and was billed without the appropriate primary procedure code. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
procedure code 64421 is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64421 billed for date of service July 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that the requested drug is medically necessary for the 
enrollee's condition. You also say that the enrollee has trial several topical treatments without success. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs. 
 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 Ilumya. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs, Remicade, Inflectra or Infliximab; and Stelara. The 
reviewer found that there is no indication that the plan's required drugs would likely be less effective and/or 
likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).