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

 
We decided that the Plan does not have to pre-approve computed tomography (CT) coronary calcium scoring. 
 
You asked the Plan to pre-approve CT coronary calcium scoring. You say that you are concerned that you may 
develop heart disease and other health problems as a result of your medical issues and medications. The Plan 
denied your request. The Plan says you do not meet criteria for this testing. 
 
The Plan follows Medicare rules. Medicare rules state that CT coronary calcium scoring is only covered under 
certain conditions. 
 
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 CT coronary calcium scoring. Our 
reviewer says that you do not meet criteria for the requested CT coronary calcium scoring test. Our physician 
reviewer found the CT coronary calcium scoring test is for decision-making regarding individuals with 
moderate 10-year risk of atherosclerotic events who need stronger reason to start statin therapy. You have 
already shown severe statin intolerance and therefore will not benefit from the results of this scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT coronary calcium scoring have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computed tomography (CT) coronary calcium scoring.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and their ongoing medical needs warrant an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the member does not meet the criteria for an LTACH 
admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve buprenorphine 15mcg/hr patch. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting reconsideration stating 
abrupt discontinuation of the requested medication could cause life-threatening side effects, and therefore is 
medically necessary for the enrollee to continue. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve buprenorphine 15mcg/hr 
patch.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia (D9222, D9223). 
 
You asked the Plan to pre-approve anesthesia. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 
anesthesia (D9222, D9223).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration stating the enrollee is medically ready to transition to the LTACH. The Plan denied your 
request. The Plan says the request for admission to an LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found that the enrollee has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) (G6002, 77014, 
77370, 77520, 77522, 77523, 77525). 
 
You asked the Plan to pre-approve PBRT. You say that the enrollee needs PBT for her life-threatening 
diagnosis of the left breast. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of proton therapy is an accepted radiation technology, that has proven efficacy and 
tolerability. Certain conditions such as base of skull chordomas and chondrosarcomas, and pediatric CNS 
malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose 
delivery to the tumor, while relatively sparing the neighboring normal tissue. For this enrollee, there are no 
planning records justifying the need for proton therapy, showing an unacceptable plan with non-proton-based 
treatment. Presumably (with no evidence otherwise) an adequate IMRT plan can readily be generated, sparing 
the heart and ipsilateral lung in this enrollee, and meeting accepted constraints based upon QUANTEC, NRG 
studies, and other sources. Routine use of proton therapy for breast cancer is not an accepted standard of care. 
IMRT that is photon based is designed to facilitate normal tissue sparing and could very readily be considered 
in this enrollee if a 3D plan is not acceptable. While proton therapy can be used (and is often used for selecting 
enrollees with unique anatomic considerations) the case file does not provide a plausible rationale for the need 
of proton therapy over conventional radiation and/or IMRT in this enrollee. The decision is unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT) (G6002, 77014, 77370, 77520, 77522, 77523, 77525).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a sacroiliac joint arthrodesis procedure. 
 
You asked the Plan to pre-approve a sacroiliac joint arthrodesis procedure. You say that a sacroiliac joint 
arthrodesis procedure is medically necessary. You say the patient is suffering from pain from a sacroiliac (SI) 
joint pain generator, and the patient has tried and failed multiple conservative measures including activity 
modification, medication optimization, physical therapy, and massage. The Plan denied your request. The Plan 
says that a sacroiliac joint arthrodesis procedure is not medically necessary. 
 
The Plan follows Medicare rules.  
 
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 sacroiliac joint arthrodesis procedure. 
Our reviewer says that the requested sacroiliac joint arthrodesis procedure is considered medically necessary in 
this case. Our physician reviewer found that the enrollee has sacroiliitis and the enrollee has been experiencing 
pain in her lower back and hip on the left side on a daily basis and the pain is affecting her ability to perform 
physical activities. Diagnostic testing has revealed pain coming from the SI joint. The enrollee has tried and 
failed conservative treatment for over six months such as activity modification, NSAIDS, narcotics, physical 
therapy, anti-convulsant medications, massage, acupuncture, yoga, and steroid injections. Some pain relief was 
achieved but the enrollee has been unable to adequately control pain long term. The pain gets worse sitting, 
standing, walking, bending forward, kneeling down, rotating to the side, driving, lifting, housework, and 
"walking stairs". The physical exam supports that the SI joint is causing the pain and would like to do the 
surgical SI joint fusion. The requested procedure meets each of the Medicare LCD criteria. The request is 
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 a sacroiliac joint arthrodesis procedure have been met. Therefore, we decided 
that the Plan has to pre-approve a sacroiliac joint arthrodesis procedure.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cognitive therapy to be provided by an OON provider. 
 
You asked the Plan to pre-approve cognitive therapy. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that these services can be provided by a 
provider in your network. 
 
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 Plan contract 
also says that your POS benefit does not apply to out-of-network therapy services. 
 
 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 
cognitive therapy to be provided by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided on September 8, 2022. 
 
You asked the Plan to pay for genetic testing. You say that this testing is supported for medical necessity. The 
Plan denied your request. The Plan says that this testing is not approved or cleared for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Therefore, we cannot determine whether the lab order made constituted plan-
directed care. Therefore, the Plan has not shown that its decision to deny payment for this is correct or justified. 
Therefore, we decided that the Plan has to pay for genetic testing provided on September 8, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,500 annual maximum limit has 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on February 21, 2023.
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 necessary. The Plan denied 
your request. The Plan says that the member does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility. 
 
  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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm device (L8702). 
 
You asked the Plan to pre-approve a MyoPro powered arm device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this 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 a MyoPro powered arm device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific 
evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for your condition or in widespread use for your condition based on scientific evidence. There 
is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for 
you. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 MyoPro powered arm device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a MyoPro powered arm device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee orthosis (L1843). 
 You asked the Plan to pre-approve the orthosis. You say that enrollee's meniscus is gone. So when the enrollee 
ambulances, they are in great pain. The Plan denied your request. The Plan says the request is not medically 
necessary because your records show you do not have knee instability, or a recent knee injury or surgery. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is ambulatory, but the documentation does not reveal evidence of objective knee 
joint laxity or instability on a physical examination. There is no evidence of a recent injury or surgery to the 
knees. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee orthosis (L1843).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy services billed for date of service February 
9, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee is getting chemotherapy for cancer. 
The Plan denied your request. The Plan says a valid primary diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We looked at the file and the rules. The claim was billed with primary diagnosis code C44.729. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the chemotherapy services billed for date of service February 
9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (procedure code 99219) rendered on 
September 4, 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 code 99219 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of moderate severity. Typically, 50 minutes 
are spent at the bedside and on the patient's hospital floor or unit." 
 
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 the decision making in this case 
was low complexity. The enrollee was primarily seeking placement and significant illnesses were excluded at 
the time of admission. 
 
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 initial observation care (procedure code 99219) rendered on September 4, 2022.