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

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT). 
 
You asked the Plan to pre-approve myocardial perfusion imaging, tomographic (SPECT). The Plan denied your 
request. The Plan says myocardial perfusion imaging, tomographic (SPECT) 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 myocardial perfusion imaging, 
tomographic (SPECT). Our reviewer says that the requested myocardial perfusion imaging, tomographic 
(SPECT) is not considered medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has no history of dyspnea or angina, per the cardiologist consultation note of January 19, 2022, and 
the electrocardiogram (ECG) was reported as normal. The enrollees pre-test probability for an abnormal test is 
low and there is documentation that the ECG is normal. 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 enrollees clinical management. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging, tomographic (SPECT) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic 
(SPECT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vasectomy (55250). 
 
You asked the Plan to pre-approve the vasectomy (55250). You say that you have two kids, and your wife is 
pregnant. You say that you are experiencing pain and have already scheduled the surgery. The Plan denied your 
request. The Plan says a vasectomy is not covered for sterilization purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that elective hysterectomy, tubal ligation, and 
vasectomy, if the primary indication for these procedures is sterilization are not covered. A sterilization that is 
performed because a physician believes another pregnancy would endanger the overall general health of the 
woman is not considered to be 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 vasectomy (55250) have not been met. Specifically, a vasectomy for the 
primary purpose of sterilization is not covered. Therefore, we decided that the Plan does not have to pre-
approve the vasectomy (55250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitoring (CGM) supplies. 
 
You asked the Plan to pre-approve CGM supplies. You say that the items are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitoring (CGM) 
supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 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 lab 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 lab services provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on August 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
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 24 one-way 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 routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77600) provided September 8, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was submitted with an invalid modifier. 
 
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 77600 is not supported in the medical record. Specifically, either Modifier XU or 59 
must be used to designate a distinct service. In this case, both modifiers were applied. Based on this 
information, we decided that Medicare rules for coverage of the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (77600) provided September 8, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with two or more power 
seat options for the enrollee. 
 
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 criteria for a simpler wheelchair may be met 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
does not reveal that the enrollee needs is at high risk for development of a pressure ulcer or utilizes intermittent 
catheterization for bladder management, or needs a power seating system to manage increased tone or 
spasticity. The documentation does not reveal that tilt and recline are medically necessary. E2377 Expandable 
Controller, E2313 Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 
2 Sys are requested to control multiple power options through the joystick.  
 As the multiple power options (power tilt and power recline) are not medically necessary therefore the request 
for Group 3 power wheelchair with multiple power options is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with two or more power seat options for the enrollee.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that considering the enrollee's medical history, 
comorbidities, current medical needs, and the severity of signs and symptoms, short-term rehabilitation is 
medically necessary. The Plan denied your request. The Plan says SNF is not medically necessary and the 
enrollee's needs can be met at a lower level of care such as home health services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female with 
dementia who was admitted to the hospital with increased confusion. She has been treated for a urinary tract 
infection and COVID 19 and remained medically stable. The most recent therapy documentation indicates the 
member currently is able to ambulate with an assistive device and requires assistance with self-care tasks. 
 
The member has stabilized medically and is ready for discharge from the hospital.  The member does not 
require skilled nursing and/or skilled therapy services on a daily basis.  She is medically stable and can receive 
further rehab services at a lower level of care.  Although further rehab services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with a CardioMEMS device. 
 
You asked the Plan to pre-approve treatment with a CardioMEMS device. You say that treatment with a 
CardioMEMS device is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for coverage of this service. 
 
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 treatment with a CardioMEMS device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found because of the clinical studies available, at this time, the CardioMEMS 
system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment with a CardioMEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve treatment with a CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you believe that admission to a SNF is 
medically necessary for you. The Plan denied your request. The Plan says your needs can be met at a lower 
level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who was 
admitted to the hospital due to an infection with influenza and decompensated congestive heart failure. The 
most recent therapy documentation indicates the member currently is able to ambulate up to 75 feet without an 
assistive device. He is able to accomplish mobility without hands on assistance.  
 
The member has stabilized medically and is ready for discharge from the hospital. The member does not 
require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive 
further rehab services at a lower level of care. Although further rehab services would be appropriate to improve 
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on July 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you feel that SNF care is medically 
necessary. The Plan denied your request. The Plan says it is not currently required to be admitted to a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who was 
admitted to the hospital with an acute stroke with resulting right sided weakness and dysarthria. He stabilized 
and was discharged to an inpatient rehab facility for intensive therapy. He has remained medically stable. The 
most recent therapy documentation indicates the member currently is able to ambulate short distances using a 
walker. He uses a wheelchair for longer distances. He required moderate assistance for some self-care tasks and 
set-up only for eating. 
 
The member has tolerated inpatient rehab services and continues to improve with daily skilled nursing and/or 
skilled therapy services. He could benefit from continued services at the current level of care. The member has 
made slow progress with therapy, and there is no indication that transfer to a skilled nursing facility is 
required. He can continue to receive skilled rehab services at the current facility or be stepped down to a lower 
level of care when appropriate.  
 
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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on August 
23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it was the nursing home's 
responsibility to obtain authorization from the Plan. The Plan denied your request. The Plan says this provider 
is out-of-network with the Plan, and authorization was not obtained prior to the services being rendered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided 
on August 23, 2021, by an out-of-network (OON) provider.