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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has increased weakness and it is making 
it difficult for the enrollee to complete their activities of daily living. The Plan denied your request. The Plan 
says the records do not support that the enrollee requires daily physical therapy and occupational therapy. The 
enrollee does not need daily skilled therapy or nursing services required to qualify for a SNF admission. The 
enrollee medical needs can be served at an alternative 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that the 
enrollee requires skilled nursing services that requires specialized skill, knowledge and judgment of a skilled 
professional nurse are not required to safely and effectively provide medically necessary and reasonable 
treatment. The enrollee does require skilled therapy services. There is no documentation that daily skilled 
services are required. Records do not document a significant decline in the enrollee's functional status to 
necessitate daily inpatient skilled therapy services. 
 
There is no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing 
facility setting. Records do not support that the services in the home or an assisted living facility with home 
health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says IRF care is not considered medically reasonable and 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 there are no complex nursing or rehabilitation needs. 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 therapeutic continuous glucose monitor (CGM) and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the CGM and supplies are medically 
necessary. The Plan denied your request. The Plan says you do not meet the requirements for approval. 
 
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 the enrollee does 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 a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary ventilation (e.g., aerosol or gas) and 
perfusion imaging (78582). 
 
You asked the Plan to pre-approve pulmonary ventilation. You say that it is medically necessary due to current 
signs and symptoms. The Plan denied your request. The Plan says the request does not meet the Medicare or 
health plan coverage criteria. The medical records do not show that there are clinical signs for pulmonary 
embolism. 
 
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 pulmonary ventilation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has cough and an abnormality on CXR. The medical records indicate the 
intent was to obtain a non-contrasted CT scan of the chest. It appears the wrong test was ordered. There is no 
suspicion of pulmonary embolism. The denial of the VQ scan is upheld. A non-contrasted CT chest would be 
considered reasonable and 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 pulmonary ventilation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve pulmonary ventilation (e.g., aerosol or gas) and perfusion imaging (78582).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Veriflex Spinal Decompression Device (22869, 22870). 
 
You asked the Plan to pre-approve a Veriflex spinal decompression device. You say that the requested device 
is necessary. The Plan denied your request. The Plan says the requested device is unproven and not medically 
necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 Veriflex spinal decompression device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature 
do not fully support the spinal decompression device procedure over the gold standard of lumbar 
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
this device for this enrollees medical condition. FDA contraindications include spinal instability, scoliosis, 
obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging 
evidence of grade 1 L3 fixed spondylolisthesis with no discussion of spinal instability on flexion/extension 
films. There is no discussion of scoliosis of the lumbar spine, with no documentation of the Cobb angle. She 
has a diagnosis of osteoporosis in her past medical history. There is no discussion indicating that a DEXA scan 
has demonstrated the lack of significant osteoporosis in the enrollee. Overall, there is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 Veriflex spinal decompression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Veriflex Spinal Decompression Device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial dentures (D5213). 
 
You asked the Plan to pre-approve maxillary partial dentures. You say that you misplaced your dentures and 
need them replaced. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 5, 2018. Therefore, 
we decided that the Plan does not have to pre-approve maxillary partial dentures (D5213).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 7, 
2021, to May 24, 2021. 
 
You asked the Plan to pay for SNF care. You say that SNF care was medically necessary on the dates in 
question. The Plan denied your request. The Plan says the provided SNF care was not medically reasonable and 
necessary. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are an 84-year-old female with cervical fusion and spinal cord compression. In 
this case on the dates in question, there were no identifiable skilled nursing service needs and no identifiable 
skilled therapy service needs. You did not require skilled nursing or therapy services on a daily basis. In 
conclusion, you did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting on the dates in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 7, 2021, to May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061 billed for date of service January 20, 
2022. 
 
You asked the Plan to pay for procedure code 77061. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 77061 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77061 billed for date of service January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET)/computed 
tomography (CT) scan services. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that the requested services are medically 
necessary and supported by the records provided. The Plan denied your request. The Plan says follow-up for 
probably adrenal adenomas may be done with computed tomography (CT) or magnetic resonance imaging 
(MRI). The Plan says that a PET/CT is not medically necessary to follow-up a probably benign adrenal 
adenoma. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pre-approve the PET/CT scan. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found that you have a history of 
adrenal lesions discovered during routine surveillance after left nephrectomy for stage I renal cell carcinoma in 
May of 2019. A PET/CT was performed on April 7, 2022, and the impression was that the adrenal lesions were 
benign adenomas. Because one of the adrenal lesions was relatively new, a follow-up was recommended. 
However, a PET/CT is not considered medically necessary to follow a benign adrenal adenoma. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve positron emission tomography (PET)/computed tomography (CT) scan services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the heavy duty wheelchair provided for rental on August 30, 2021. 
 
You asked the Plan to pay for the heavy duty wheelchair rental. You say that the records support that the 
equipment was necessary. The Plan denied your request. The Plan says that the order indicates that a standard 
wheelchair was ordered by the provider. There is a more appropriate code for this type of wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty wheelchair is covered for enrollees 
weighing over 250 pounds.  
 
We looked at the file and Medicare rules. Though the physician order does indicate a standard wheelchair, the 
enrollee's weight is 290 pounds well over the requirement to qualify for a heavy duty wheelchair. While the 
order is part of determining coverage, we find that the supplier is also required to provide equipment that meets 
the enrollee's needs. As the enrollee's weight is well-documented in the record, we find that provision of a 
heavy duty wheelchair is appropriate and meets coverage criteria. Based on this information, we decided that 
Medicare rules for coverage of the heavy duty wheelchair rental have been met. Therefore, we decided that the 
Plan has to pay for the heavy duty wheelchair provided for rental on August 30, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy services provided on November 10, 
2021, billed with code 52332-59. 
 You asked the Plan to pay for the services as billed. You say that this was billed correctly, and both codes 
should be paid. The Plan denied your request. The Plan says the use of the modifier is not supported to allow 
separate payment. 
 
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 52332 is a column II code to column I code 52356; however, 52332 
was billed with a modifier.  
 
We asked our coder 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 as billed. Our reviewer says that the 
documentation does not support that the modifier used for the Column 2 code is clinically appropriate to allow 
for bypass of the edit. Our reviewer found the procedure report describes cystoscopy, left ureteral 
catheterization balloon dilation with left lower ureteroscopy stone extraction, and retrograde pyelogram and 
insertion of a left double-J stent.  In this case, the procedures were performed same anatomical location, and 
therefore would not be reported separately.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the cystourethroscopy services provided on November 10, 2021, billed with code 
52332-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions to be provided by a network provider. 
 
You asked the Plan to pre-approve the dental extractions. You say that you have roots that are exposed which 
requires extractions performed by a maxillofacial specialist. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental extractions to be provided by a network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 7, 
2021, through October 8, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from October 7, 2021, through October 
8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a health club membership provided on January 1, 2022. 
 
You asked the Plan to pay for a health club membership. You say that you have called four times and were told 
different information. You also say that you were even told you had a check coming, and when you called to 
file the appeal, you were told it was denied. The Plan denied your request. The Plan says they did not receive 
an itemized bill or proof of payment for an established health club. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the reimbursement forms, proof of payment and any additional information outlined on the form is 
received. 
 The Plans rules for coverage of gym benefits have not been met because the Plan did not receive all the 
necessary documents. Therefore, we decided that the Plan does not have to pay for a health club membership 
provided on January 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab. 
 
You asked the Plan to pre-approve Nivolumab. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says Nivolumab is not being prescribed for a medically-
accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Nivolumab. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with non-small cell lung cancer. In this case, the requested use of Nivolumab is not FDA-approved 
for the enrollees diagnosis. Specifically, Nivolumab is indicated for 1st line therapy and the enrollee has 
progression on prior Programmed death-ligand 1 (PDL1) directed therapy. Furthermore, the use of Nivolumab 
is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-
approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nivolumab.