Persius/hicric huggingface dataset:
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 denial of coverage at the IRF will seriously 
jeopardize the enrollee's life, health and ability to regain function. You say skilled nursing facility care will not 
give the enrollee the best opportunity to regain their baseline quality of life. The Plan denied your request. The 
Plan says the request for admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided on January 13, 2023. 
 
You asked the Plan to pay for the brace. You say that you told the provider you did not want the back brace. 
The Plan denied your request. The Plan says this service was related to a prohibited telemarketing contact. 
 
The Plan must follow Medicare rules. Medicare rules say that all DMEPOS items require a written 
order/prescription from the treating practitioner for Medicare payment as a condition of payment. 
 
We looked at the file and Medicare rules. The submitted documentation in this case does not show that the 
servicing provider is the enrollee's treating practitioner, nor does the enrollee have any relationship with the 
servicing provider. Based on this information, we decided that Medicare rules for coverage of the brace have 
not been met. Therefore, we decided that the Plan does not have to pay for the back brace provided on January 
13, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing provided on December 5, 2022, billed with 
code G0482. 
 
You asked the Plan to pay for the drug testing as billed. You say that this was correctly billed for medically 
necessary testing.  The Plan denied your request. The Plan says that the billed code is not supported as only 10 
drug classes are documentedon the lab report. 
 
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 G0482 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, review of the lab report 
confirms that there were 15 reportable drug classes tested per the CPT Codebook. We note that several drugs 
within the Opiates/Opioids and Opioids Synthetic drug class on the report have separately reportable codes in 
the codebook, such as oxycodone and tramadol, for example. Based on this information, we decided that 
Medicare rules for coverage of the drug testing as billed have been met. Therefore, we decided that the Plan has 
to pay for the definitive drug testing provided on December 5, 2022, billed with code G0482.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vancomycin. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting reconsideration stating the 
medication is medically necessary for the enrollee's treatment. 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 vancomycin.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture. 
 
You asked the Plan to pre-approve a partial lower denture. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial lower denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit provided on January 11, 2023, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with rituximab (J9312). 
 
You asked the Plan to pre-approve rituximab. You say that rituximab is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says rituximab has been prescribed for an off-label, not medically 
accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 rituximab. Our reviewer says that 
rituximab is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of rituximab is not FDA-approved for the enrollees diagnosis. The use is not supported by one 
of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rituximab have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with rituximab (J9312).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869, 99152, 99153). 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that you are trying to get the requested 
procedure covered because you cannot get back surgery due to your health. The Plan denied your request. The 
Plan says unproven and not medically necessary procedures are not covered by Medicare. 
 
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 Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the Vertiflex device is experimental and investigational. There is more 
research needed due to insufficient evidence of efficacy. 
 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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device (22869, 99152, 99153).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the CardioMEMS device at this point should only be approved for patients enrolled 
in a clinical trial. The Plan states there is no indication that this enrollee is enrolled in a clinical trial of the 
device. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 enrollees 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 (33289 and C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete breast peri-implant capsulectomy with 
removal and replacement of breast implant. 
 
You asked the Plan to pre-approve a complete breast peri-implant capsulectomy with removal and replacement 
of breast implant. 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 procedures will be considered cosmetic (which is not 
a covered Medicare benefit) or not medically reasonable and necessary when performed certain reasons 
 
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 complete breast peri-implant 
capsulectomy with removal and replacement of breast implant. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found based on the medical records provided there is no 
documentation that the complete breast peri-implant capsulectomy with removal and replacement of breast 
implant at issue in this case meet all Medicare criteria for medically reasonable and necessary for the enrollee. 
Without documentation of the enrollee's consent for the procedure, provided records in this case do not 
document the surgery is being 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 a complete breast peri-implant capsulectomy with removal and replacement of 
breast implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete 
breast peri-implant capsulectomy with removal and replacement of breast implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth nursing facility care provided on February 13, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for telehealth nursing facility care. You say that the enrollee could not choose an in-
network provider. The Plan denied your request. The Plan says this was not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 telehealth nursing facility care provided on 
February 13, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 22, 2022, billed 
with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651, 
and 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is correctly billed for medically 
necessary testing.  The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 22, 2022, billed with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87563, 
87591, 87661, 87481, 87651, and 87653.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve the myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated 
technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or 
pharmacologic) and/or redistribution and/or rest reinjection (78452). 
 
You asked the Plan to pre-approve the SPECT. You say that you are requesting reconsideration stating due to 
abnormal electrocardiogram (EKG) and other variables the enrollee is unable to ambulate on treadmill due to 
unsteady gait and uses a rolling walker. The Plan denied your request. The Plan says that the Medicare rules 
have not been 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 the SPECT. Our physician reviewer 
found a chemical nuclear myocardial perfusion imaging (MPI) test is reasonable in this asymptomatic 
individual with elevated troponin., diabetes mellitus (DM), abnormal electrocardiogram (ECG), old inferior MI & T wave abnormalities- and limited exercise capacity, prior to a intermediate risk elective surgery. Therefore, 
the testing is necessary, and the enrollee meets criteria. 
 
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 SPECT have been met. Therefore, we decided that the Plan has to pre-
approve the myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative 
or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when 
performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest 
reinjection (78452).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that there is no correlation between the exam and the imaging. There was no electromyography (EMG) 
testing. The surgery is not needed based on the available records. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenic stimulator. 
 
You asked the Plan to pre-approve an osteogenic stimulator. 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 the noninvasive stimulator device is covered only for 
certain indications. 
 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 an osteogenic stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the 90-day period has not 
elapsed and the request is, at this point, 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 an osteogenic stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an osteogenic stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special mattress (E1399). 
 
You asked the Plan to pre-approve a special mattress. You say that the requested mattress is used when an 
enrollee cannot tolerate the air fluidized therapy, or the enrollee's home cannot accommodate the 1100-pound 
air fluidized therapy bed. The alternate bed would not meet the enrollee's bariatric needs and would not lower 
enough to assist with transfer on/off the bed. It is medically necessary that the enrollee is approved for the 
requested mattress. The Plan denied your request. The Plan says the requested mattress must be requested with 
the correct code. The correct code was not used. 
 
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 code E1399 is not supported in the medical record. Specifically, code E1399 is not a code 
that can be used for the requested mattress. The correct code for a group 3 surface is E1094. Based on this 
information, we decided that Medicare rules for coverage of a special mattress have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a special mattress (E1399).