Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001), also 
known as US-IGRT. 
 
You asked the Plan to pre-approve the IGRT. You say that the requested services are medically necessary. The 
Plan denied your request. The Plan says the requested services are not medically necessary for skin cancer.  
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found certainly using ultrasound on a daily basis is not unreasonable to offer, but not necessary. The 
device itself is Food and Drug Administration (FDA) approved for use with ultrasound though that in and of 
itself does not mean that daily imaging is necessary but simply that the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or image-guided radiation therapy (IGRT) for 
a technology for which need has not been established by published data or supported by consensus guidelines is 
not necessary. Our physician reviewer's decision is unfavorable as billing for daily IGRT which would not be 
furnished in accordance with accepted standards of medical practice.  
 
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 IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound guided radiation therapy (G6001), also known as US-IGRT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary-
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure 
support (AVAPS) capability and failure of such a device has not been documented. The Olan has indicated 
coverage for such a device is available upon request. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
21, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega 3 skin substitute (Q4158, 15275). 
 
You asked the Plan to pre-approve Kerecis Omega 3 skin substitute. 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 Kerecis Omega 3 skin substitute. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Kerecis Omega 3 skin substitute is a decellularized intact fish skin 
developed for the management of chronic wounds, such as diabetic wounds, pressure ulcers, and vascular 
ulcers, as well as surgical wounds (dehiscence or failed healing after surgery). The documentation does not 
support that the enrollee has an indication for Kerecis Omega 3 skin substitute.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis Omega 3 skin substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Kerecis Omega 3 skin substitute (Q4158, 15275).
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 services requested are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
LTACH services. 
 
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 the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that your provider put in a request for a power 
wheelchair instead of power scooter. You also say that you had the power wheelchair returned and now have 
nothing The Plan denied your request. The Plan says there was no physician order recieved. 
 
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 a power scooter have been met. Specifically, the Plan requires you to use a Primary Care Provider to coordinate your care. The records 
provided do not include an order for a power scooter. Therefore, we decided that the Plan does not have to pre-
approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services reported with DRG 682 rendered 
from March 6, 2021, to March 10, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration. The Plan denied your request. The Plan says a post-
service, post-payment clinical validation audit was performed to help ensure that the diagnosis codes on the 
claim were supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 682. 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 the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee is noted to be morbidly obese. While the enrollee may have micronutrient deficiencies, the 
enrollee is not severely calorie malnourished. As such, the billing of E43 is not supported.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services reported with DRG 682 rendered from March 6, 2021, to March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional chiropractic visits. 
 
You asked the Plan to pre-approve 3 additional chiropractic visits. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that chiropractic services are covered when specific 
criteria are met. 
 
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 3 additional chiropractic visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the records of these 
visits do not support progressive improvement of symptoms but rather maintenance therapy. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 additional chiropractic visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 3 additional chiropractic visits.
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 you are not getting the medical care or therapy you 
need to be able to return home safely. The Plan denied your request. The Plan says the services you need can be 
provided safely in other settings.  
 
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 you are medically stable and do not need a physician's supervision 3 times a week in 
an IRF. Your rehabilitation needs can be safely provided in an alternate and low intensity setting. 
 
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 Gammagard (immune globulin) solution. 
 
You asked the Plan to pre-approve the medication. You say that the continuation of the medication is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a stated diagnosis of common variable immunodeficiency. The record provided documents chronic sinusitis 
and is insufficient to establish the stated diagnosis. The Food and Drug Administration (FDA) has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard (immune globulin) solution.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a rheumatologist. 
 
You asked the Plan to pre-approve the rheumatologist office visit. You say that you thought the Health Plan 
was going to handle your appointment with the arthritis doctor without your primary care provider (PCP) 
interfering; however, at the last minute you were told you cannot go because your PCP did not submit referral. 
The Plan denied your request. The Plan says your primary care provider (PCP) is in disagreement with the 
request and needs you to contact the PCP office. 
 
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 rheumatologist office visit. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that you are experiencing pain in both legs, underneath your stomach and in your back. There is no specific clinical rationale for a Rheumatology evaluation at this 
time. You need to follow-up with your PCP. The review has determined that the items/services at issue in this 
case are 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 the rheumatologist office visit have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an office visit with a rheumatologist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the ultrasound service provided on March 14, 
2023.  
 
You asked the Plan to waive the charges for the ultrasound. You say that you were under the impression that 
this was a fully covered test that was necessary prior to your surgery.  The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for radiological diagnostic services, not including x-rays.  
 
 You have been asked to pay $90.81 for the ultrasound, which is less than the applicable $120 copayment. This 
item/service falls within the radiological diagnostic services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. Coverage for this service was not denied. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the charges for the ultrasound service provided on March 14, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the right sacroiliac joint fusion (0775T and 77003). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 services. Our physician reviewer 
found there are multiple other plausible pain generators including at the lumbosacral spine are evident. The 
computed tomography (CT) of the pelvis only noted mild degenerative arthropathy mid inferior sacroiliac. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested right sacroiliac joint fusion 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the right sacroiliac joint fusion (0775T and 77003).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a ventilator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee requires effective nocturnal 
ventilation. The Plan denied your request. The Plan says there is no support that the ventilator is being used as 
intended. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 requested services. Our physician 
reviewer found that the enrollee has diagnoses of obstructive sleep apnea and restrictive lung disease due to 
obesity hypoventilation syndrome. The home ventilator is being requested for use in an average volume 
assured pressure support (AVAPS) mode which is a modality that could be provided by a bilevel positive 
airway pressure (BiPAP) device with AVAPS and a back-up rate. Ventilators used to provide BiPAP therapy 
are not reasonable and necessary. The provided records in this case do not provide adequate detailed 
information to meet Medicare criteria for coverage of a ventilator. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued use of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99214) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 
office visits (99204, 99214) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305) provided on March 20, 2023. 
 
You asked the Plan to pay for pathology services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says this claim was submitted with two 
incompatible diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of pathology services have not been met. Specifically, this claim was submitted with diagnosis codes 
D12.3 and K63.5. However, codes within the D12 code set have an Excludes1 note with code K63.5. This 
means it is generally inappropriate to report these diagnoses together. Therefore, we decided that the Plan does 
not have to pay for pathology services (88305) provided on March 20, 2023.