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

 
We decided that the Plan does not have to pre-approve Vectibix (J9303), fluorouracil (J9190), irinotecan 
(J9206) and leucovorin (J0640). 
 
You asked the Plan to pre-approve Vectibix (J9303), fluorouracil (J9190), irinotecan (J9206) and leucovorin 
(J0640). The Plan denied your request. The Plan says Vectibix (J9303), fluorouracil (J9190), irinotecan (J9206) 
and leucovorin (J0640) is not medically necessary. 
 
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 Vectibix (J9303), fluorouracil (J9190), 
irinotecan (J9206) and leucovorin (J0640). Our reviewer says that Vectibix (J9303), fluorouracil (J9190), 
irinotecan (J9206) and leucovorin (J0640) is not medically necessary. Our physician reviewer found that the 
requested use of Vectibix, fluorouracil, irinotecan and leucovorin are not FDA-approved. Vectibix, 
fluorouracil, irinotecan and leucovorin are also not supported by one of the major drug compendia or by 
clinical research. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vectibix (J9303), fluorouracil (J9190), irinotecan (J9206) and leucovorin 
(J0640). have not been met. Therefore, we decided that the Plan does not have to pre-approve Vectibix (J9303), 
fluorouracil (J9190), irinotecan (J9206) and leucovorin (J0640).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053, 80061, 85025) provided on May 5, 
2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 codes 80053, 80061, & 85025 are not supported in the medical record. Specifically, the lab 
order provided is not legible. The plan requested additional records and none were provided. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (80053, 80061, 85025) provided on May 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital admission. 
 
You asked the Plan to pre-approve inpatient hospital admission. You say that you want the Plan to approve the 
services. The Plan denied your request. The Plan says the enrollee was not a member with this Plan until 
November 1, 2023. The insurance carrier who the enrollee was enrolled with at the time of the admission on 
October 24, 2023, is responsible for the admission. 
 
The Plan must follow Medicare rules. Medicare rules say that when coverage under an MA plan begins while 
the beneficiary is inpatient, payment for inpatient services until the date of the beneficiarys discharge is made 
by the previous MA organization or original Medicare, as appropriate.  
 
We looked at the file and Medicare rules. The records show that the enrollees inpatient hospital stay began on 
October 24, 2023. The enrollee was not active with this MA Plan until November 1, 2023. The responsible 
party is the insurer that the enrollee was active with at the time of admission. Based on this information, we 
decided that Medicare rules for coverage of inpatient hospital admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH. You also say the enrollee cannot be adequately cared for in their current condition at a 
skilled nursing facility. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for admission to an LTACH.  
 
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 was admitted for a chronic obstructive pulmonary disease (COPD) 
exacerbation. The enrollee's course was complicated by sepsis, acute kidney injury, and hyperglycemia. The enrollee never required mechanical ventilation but does require 3 liters of oxygen via nasal cannula during the 
day and bilevel positive airway pressure (BIPAP) at night. The enrollee's needs at this time do not suggest a 
greater than 25-day hospitalization and their needs are not sufficient to rise to the level of LTACH admission. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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, for 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 3, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes A0431 and A0436 provided on October 21, 2021. 
 
You asked the Plan to pay for procedure codes A0431 and A0436. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that they are not the enrollee's 
primary insurer. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure codes A0431 and A0436 based on Medicare criteria. The Plan provided no 
documentation proving they are not the enrollee's primary insurer. Therefore, we decided that the Plan has to 
pay for procedure codes A0431 and A0436 provided on October 21, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the knee. 
 
You asked the Plan to pre-approve MRI of the knee. You say that this is medically necessary. The Plan denied 
your request. The Plan says criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI of the knee. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested MRI of the knee is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the knee have not been met. Therefore, we decided that the Plan does 
not have to pre-approve MRI of the knee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 provided on April 27, 2023. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 The Plan must follow Medicare rules. Medicare rules say while a physician order is not required to be signed, 
the physician must clearly document, in the medical record, the intent that the test be performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, medical records submitted 
do not include an order that specifically list what test(s) are to be performed in the custom panel. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0482 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0482 provided on April 27, 
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 the enrollee does not meet the requirements for an 
IRF admission. The Plan denied your request. The Plan says a lower level of care is not sufficient or safe to 
provide the enrollee the ample services needed for optimal recovery.  
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in a lower level of care. There is documentation that there is a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from an intensive rehabilitation program provided in an 
IRF, but the services required can be provided 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the cervical spine. 
 
You asked the Plan to pre-approve MRI of the cervical spine. You say that the enrollee has severe pain in her 
neck, shoulder and arm and needs an MRI to find out why. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI of the cervical spine. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has neck pain. The record provided does not indicate the presence of red flag signs or symptoms, 
abnormal neurological examination findings, or the failure of a trial of conservative therapy. The requested 
service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical 
condition at this time. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve MRI of the cervical spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injection. 
 
You asked the Plan to pre-approve genicular nerve branch injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says this does not meet the LCD criteria. 
 
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 genicular nerve branch injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is an experimental/ investigational procedure. It is the subject of 
ongoing clinical trials. Therefore, the request is deemed not 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 genicular nerve branch injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two replacement toe fillers (L5000). 
 
You asked the Plan to pre-approve two replacement toe fillers. You say that the items should be covered. The 
Plan denied your request. The Plan says this is request of convenience and not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve two replacement toe fillers (L5000).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy services provided on January 6, 2023. 
 
You asked the Plan to pay for the physical therapy services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that your status shows as opting out of Original Medicare 
participation. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan has denied this claim stating that the 
provider has opted out. The documentation and opt-out website does not support that this provider and NPI has 
opted out. No other denial rationale was provided. This means the Plan did not substantiate their denial. 
Therefore, we decided that the Plan has to pay for the physical therapy services provided on January 6, 2023.  
 
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: Favorable

 
We decided that the Plan has to pre-approve the alternative medicine acupuncture. 
 
You asked the Plan to pre-approve the alternative medicine acupuncture. You say that your primary care 
physician has given you a referral for acupuncture, but you have been unable to get an appointment with the 
provider. The Plan denied your request. The Plan says that the plan has contracted with American Specialty 
Network to provide acupuncture. 
 
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 follows these rules. 
 
You were referred for the alternative medicine acupuncture by a contract provider. It is inappropriate for a Plan 
to receive a request for a covered service and not forward it to the applicable third party if the Plan chooses to 
use one to administer that benefit. A Plan must ensure that a coverage determination request is answered 
whether directly or through its agent. Under Medicare rules, this means the alternative medicine acupuncture is 
considered approved by the Plan. Therefore, we decided that the Plan has to pre-approve the alternative medicine acupuncture. 
  
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the lumbar spine. 
 
You asked the Plan to pre-approve MRI of the lumbar spine. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested MRI is not medically necessary and does not satisfy the 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI of the lumbar spine. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the MRI does not appear 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 MRI of the lumbar spine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MRI of the lumbar spine.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee's diagnosis would be consistent with 
early Alzheimer's disease for which there is an infusion therapy available which would make a difference in the 
enrollee's disease. The Plan denied your request. The Plan says a PET scan is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are 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 the PET scan. Our reviewer says that a 
PET scan is not medically necessary. Our physician reviewer found that the enrollee is only potentially 
suspected of having AD and nothing to suggest the presence of both AD and FTD or that the enrollee has 
satisfied diagnostic criteria for both conditions. Furthermore, other causes of cognitive impairment have not 
been rules out. Therefore, the request would not meet the criteria for coverage. 
 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 scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from April 1, 2023 to April 25, 2023, 
by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the services. You say that you are Medicare-certified, and this patients plan is a 
Medicare Advantage plan. You also say that as medically necessary, services were rendered to the patient, you 
are requesting payment to be made in the usual and customary amount. The Plan denied your request. The Plan 
says these services were rendered by a non-network provider who does not work with the patients health plan, 
and the patient was referred by a provider who also does not work with the Plan. The Plan also says that no 
medical necessity for an OON provider, such as an urgent or emergency situation, has been documented. 
 
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 
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 the services provided from April 1, 2023 to April 
25, 2023, by an out-of-network (OON) provider.