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 you have nobody at home to take care of you and 
you are unable to take care of yourself and need rehab care. The Plan denied your request. The Plan says your 
needs appear to be custodial in nature and can be met at a lower level of care. 
 
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 do not require treatment by multiple therapies. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the therapy. 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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that certainly using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device 
itself is 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 (77280- also requested in this case) and/or IGRT for a technology for which need has not been established by published data or supported by consensus guidelines (many of which recommend against 
treatment with these devices in general- citations below) is not 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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound-guided radiation therapy (IGRT).
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 requesting for inpatient rehab to regain 
mobility skills to be able to perform daily activities alone. The Plan denied your request. The Plan says you do 
not 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 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. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bronchoscopy services (procedure code 31653) rendered on 
July 26, 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 31653 is "Bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or 
transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations 
or structures." 

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 documentation submitted does 
not include documentation of a bronchoscopy procedure. The medical record includes a pathology report; 
however, a bronchoscopy cannot be verified, as this procedure was not found in documentation submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for bronchoscopy services (procedure code 31653) rendered on July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are a fall risk and need assistance to walk due to 
the wounds on your leg. The Plan denied your request. The Plan says the IRF care is not medically necessary, 
and your needs can be met at a lower level of care such as a skilled nursing facility, home with health services, 
or home with outpatient therapy. 
 
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 were evaluated in the Emergency Department for lower extremity swelling and 
pain and was discharged home.  Your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. 
 
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: Favorable

 
We decided that the Plan has to pre-approve the Prolia. 
 
You asked the Plan to pre-approve the Prolia. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says that the drug is not medically necessary. 
 
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 the Prolia. Our reviewer says that the 
drug is medically necessary. Our physician reviewer found the requested use of Prolia is FDA-approved for the 
enrollees diagnosis and its use is supported by one of the major drug compendia or by clinical research that 
appears in an 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 the Prolia have been met. Therefore, we decided that the Plan has to pre-
approve the Prolia.  
 
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 the dental services on January 19, 2023. 
 
You asked the Plan to pay for the dental service (D0431). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service is 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 pay for the dental 
services on January 19, 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 would greatly benefit from this service. 
The Plan denied your request. The Plan says the enrollee's needs may be met with less frequent therapy 
services in a long-term care 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 the enrollee does not require treatment by multiple therapies. 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crown - full cast predominantly base metal (D2791). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of the 
requested service. The Plan denied your request. The Plan says that the request does not meet criteria. 
 
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. Specifically, we requested digital x-rays and did not receive them. Without clear 
digital x-rays we cannot determine if you meet criteria. Therefore, we decided that the Plan has to pre-approve 
crown - full cast predominantly base metal (D2791).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON oncology care. You say that your plan oncologist is slow in returning 
your phone calls.  You also said that you have not received the plan's denials. The Plan denied your request. 
The Plan says care is available with several different in-network oncologists. 
 
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 
oncology care to be provided 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 October 20, 2022, billed with 
codes 81272, 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
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 
October 20, 2022, billed with codes 81272, 81314 and 81345.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with related electronic 
connections (E2311) and harness (E2313), power seat elevation feature (E2300), high-resolution joystick 
(K0108), and lateral positioning cushion (K0108) for use with an approved power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair options and accessories. You say that the requested 
items should be approved. The Plan denied your request. The Plan says all necessary items were approved. The 
components that remain denied are not medically necessary or 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 the power wheelchair options and 
accessories. Our reviewer says that the requested expandable controller is not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has paraplegia secondary to a spinal 
hemorrhage. She has at least 3+/5 strength in upper extremities. Neurosurgery found her strength 5/5. Physical 
therapy reported it to be 3+/5. As the enrollee has adequate strength in upper extremity to manage standard 
power drive controls, the expandable controller is not medically necessary. 
 
We also find that the requested power seat elevation system is noncovered by Medicare. In addition, the code 
K0108 requested for a high-resolution joystick cannot be approved as the expandable controller has not been 
approved. Lastly, K0108 for the lateral positioning cushion is incorrect coding as the approved cushion code 
includes all cushion necessary for the wheelchair.  
 
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 power wheelchair options and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller (E2377) with related electronic 
connections (E2311) and harness (E2313), power seat elevation feature (E2300), high-resolution joystick 
(K0108), and lateral positioning cushion (K0108) for use with an approved power wheelchair.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit for the evaluation and management of a new patient 
(99203) and the x-ray exam of the cervical spine (72040) provided on November 22, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that these services are not a covered benefit. 
 
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. Specifically, the Plan has stated that the services at issue are not a covered 
benefit. However, the Plan contract states that supplemental coverage is provided for chiropractic services. This 
benefit includes new and established patient examinations and select x-ray procedures. The Plan has not 
provided evidence that indicates you do not meet criteria for coverage of the services provided in this case 
under the supplemental benefit. The Plan has not substantiated their denial; therefore, we must find in your 
favor. Therefore, we decided that the Plan has to pay for the office visit for the evaluation and management of a 
new patient (99203) and the x-ray exam of the cervical spine (72040) provided on November 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genetic panel described as Tempus xF (81455). 
 
You asked the Plan to pre-approve a genetic panel. 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 effective for services performed on or after March 16, 
2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing 
(NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a 
Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating 
physician, and when certain requirements 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 a genetic panel. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the review indicates that the enrollee is 
a 70-year-old female with a history of Stage IIb Squamous cell Ca of the lung status post chemotherapy and 
radiotherapy. The review has determined that the enrollee does not meet the coverage criteria detailed in the 
NCD. 
 
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 genetic panel have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genetic panel described as Tempus xF (81455).
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 services are medically necessary to actively 
manage the enrollee's medical needs and optimize recovery. The Plan denied your request. The Plan says 
ongoing skilled care can be provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. 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.