Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered meals. 
 
You asked the Plan to pre-approve home delivered meals. You say that you have a history of surgery and other 
health issues and need healthy meals. The Plan denied your request. The Plan says the diagnosis at time of 
discharge on September 3, 2022, was thrombosis of unspecified artery. Therefore, does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that home delivery of meals may be offered as a 
supplemental benefit if the services are: 1) Needed due to an illness; 2) Consistent with established medical 
treatment of the illness; and 3) Offered for a short duration. The Plan offers home-delivered meals benefit when 
the enrollee is discharged from a hospital as an inpatient due to congestive heart failure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home delivered meals have not been met. Therefore, we decided that the Plan does not have to pre-
approve home delivered meals.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram, routine ECG with at least 12 leads; 
tracing only, without interpretation and report provided to the enrollee on July 7, 2022. 
 
You asked the Plan to pay for the ECG. You say that this should be paid for. The Plan denied your request. The 
Plan says this code has a status indicator of Q1 and is not separately payable. 
 
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, the CPT Code Manual definition of code 93005 is "Electrocardiogram, routine ECG with at least 
12 leads; tracing only, without interpretation and report." 
 
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 ECG. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the medical records do not support the 
use of procedure code 93005 in the documentation submitted. 
 
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 ECG have not been met. Therefore, we decided that the Plan does not have 
to pay for an electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and 
report provided to the enrollee on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 12, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure codes 00752, 64488) provided 
to the enrollee on April 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 00752: 
 
Anesthesia for hernia repairs in upper abdomen; lumbar and ventral (incisional) hernias and/or wound 
dehiscence 
 
CPT 64488: 
 Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections 
(includes imaging guidance, when performed) 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 00752, the 
procedure report describes anesthesia provided for Inguinal hernia repair right abdomen. In this case, there is a 
more appropriate code to report, and anesthesia for hernia repairs in upper abdomen cannot be verified. For 
CPT 64488, although it is documented in the records, the primary anesthesia services were reported incorrectly. 
Therefore, this procedure would not be covered. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services (procedure codes 00752, 64488) provided to the enrollee on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says if the enrollee uses an out-of-network provider, the provider must be 
eligible to participate in Medicare and/or Medi-Cal. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have 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 that the enrollee was admitted for urinary tract infection after a recent stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. In this case, the enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Zilretta have been met. In this case, the 
Plan attempted to reach out for medical records supporting Zilretta. No medical records were returned to 
support a step therapy exception. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be approved. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and 
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure 
in the management of patients with congestive heart failure. The clinical study on which FDA approval was 
based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. 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. 
 
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 Leqvio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no evidence that the enrollee has 
tried and not responded to Praluent. There is no documentation as to why Praluent would not be expected to be 
safe and effective for the enrollee. Therefore, the requested Leqvio is not shown to be currently medically 
necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have the services a dual-energy X-ray absorptiometry (DEXA), bone density 
study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) provided to the enrollee on January 28, 2022. 
 You asked the Plan the services the services. You say that medical records were provided, and the claim should 
be reprocessed. The Plan denied your request. The Plan says it cannot be determined how the enrollee came to 
the servicing provider, or whether the services are 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 the services the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee had a DEXA scan on 1/28/22 which was ordered by the doctor. The reason for the exam 
was dictated as "osteopenia" but there were no comparison exams cited in the report. The submitted materials 
did not include any records from the ordering physician in order to determine medical necessity. 
 
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 the services a dual-energy X-ray absorptiometry (DEXA), bone density study, 1 or more sites; axial 
skeleton (eg, hips, pelvis, spine) provided to the enrollee on January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
June 29, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically necessary and reasonable. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. In addition, the Place of Service code for this claim was not reported in accordance 
with Medicare billing guidelines. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service  
May 1, 2022, to May 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 1, 2022, to May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has a past medical history of COPD and is living at home with weakness 
and deconditioning after a COVID infection in September 2022. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac positron emission tomography (PET) scan. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is clinically stable with no 
clinical change since the last cardiac PET scan performed in 2021. There is no evidence in the submitted 
records to support a repeat cardiac PET scan. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cardiac positron emission tomography (PET) scan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from January 
16, 2020, to February 19, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported properly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We find that the services are not supported in the medical record. Specifically, the last day on this claim, the 
"through" date is the 35th day instead of the 29th day. 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 pay 
for home health services provided to the enrollee from January 16, 2020, to February 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need to have a procedure done for 
breathing issues. The procedure cannot be done in your area, and you must travel to a facility which is more 
than 50 miles away. The Plan denied your request. The Plan says you are requesting an additional 72 miles for 
a total of 122 miles and your benefit only allows 50 miles. The Plan also says you have exceeded your benefit 
limit. 
 
 
 
 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 up to 36 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 21, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says records were not 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. The 
submitted documentation does not contain medical records from the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on June 21, 2022.