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

 
We decided that the Plan does not have to pre-approve a PET scan concurrently with a CT scan of the head. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that the enrollee has mild cognitive impairment, 
and the PET scan is needed to determine the etiology. The Plan denied your request. The Plan says the criteria 
for coverage have not been met. 
 
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/CT scan. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the record indicates the enrollee 
is only suspected of having AD. The record provided does not establish that the enrollee meets the diagnostic 
criteria of both AD and FTD. The elements of the coverage criteria are not satisfied. The requested service 
cannot be covered 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 the PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a PET scan concurrently with a CT scan of the head.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electric patient lift with seat/sling. 
 
You asked the Plan to pre-approve the lift. You say that the current hydraulic lift is not reliable. The Plan 
denied your request. The Plan says that the notes show that the enrollee has a Hoyer lift. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 lift. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the current lift is not meeting the enrollee's needs, as it is causing caregiver burden. The plan has not 
provided any data or assessment of the appropriateness of the current device in the home. 
 
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 lift have been met. Therefore, we decided that the Plan has to pre-approve 
an electric patient lift with seat/sling.  
 
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 pay for the compounded drug for inhalation (J7999) provided on 
June 26, 2023. 
 
You asked the Plan to pay for the compounded drug. You say that this service was reported correctly. The Plan 
denied your request. The Plan says this code must be reported with the KD modifier as it was a compounded 
drug which will be administered through DME. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that compounded drugs which will 
be administered through durable medical equipment (DME) must have the KD modifier appended to the 
appropriate procedure code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the compounded drug have not been met. Specifically, it is indicated that the drug at issue will be 
administered through DME, but code J7999 was not reported with modifier KD as required. Therefore, we 
decided that the Plan does not have to pay for the compounded drug for inhalation (J7999) provided on June 
26, 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 you do not have any strength and will need a more 
vigorous therapy team to assist with mobility. The Plan denied your request. The Plan says the IRF services 
requested do not meet the requirements for approval.  
 
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 your medical complexity does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. You do not require an intensive rehabilitation therapy, and it is 
unclear if you would be able to tolerate. There is not a reasonable expectation that you will be able to benefit 
from the intensive rehabilitation program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E1007, 
K0843, E0955, E1028, E1012, E2311, E2313, E2377, E2361, E2602, E1028). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary for the enrollee's condition. The Plan denied your request. The Plan 
says the enrollee does not have a qualifying diagnosis causing mobility limitation for a power wheelchair. As 
the base code for the requested wheelchair is not reasonable and necessary, none of the requested accessories 
can be approved. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has neuropathy. He has intact skin, does not use a catheter 
and is able to stand. The enrollee lives alone with caregiver assistance 4 hours per day, 3 times per week. Per 
L33789, the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity 
or require an alternative means of managing power drive. The enrollee does not meet criteria for approval of 
the requested items. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E1007, K0843, E0955, 
E1028, E1012, E2311, E2313, E2377, E2361, E2602, E1028).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95811). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for an in-lab sleep study. A home sleep test 
would be approved if requested. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies can be 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 a sleep study. Our reviewer says that 
the enrollee does not meet criteria for an inpatient sleep study. Our physician reviewer found there is no 
indication at this time for an inpatient or split sleep study. The enrollee can safely undergo a home sleep study. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95811).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64635, 64636). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the procedure will help correct your 
lumbar on both sides of your spine. The Plan denied your request. The Plan says radiofrequency ablations are 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have chronic low back pain. You had diagnostic medial branch blocks on July 
27, 2023, which produced 80% pain relief. There is no documentation of a second set of diagnostic MBBs. The 
LCD requires documentation of a second set of diagnostic blocks that also produces 80% pain relief. This is not 
present; 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (64635, 64636).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99284) provided 
on July 7, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99284). You say that procedure code 
99284 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 an emergency department visit (procedure 99284). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the enrollee was evaluated in the emergency department (ED) for worsening of a known pressure wound 
following recent elective surgery. An appropriate history and physical were documented; However, the records 
do not support a moderate level of medical decision. As such, the billing of CPT 99284 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99284) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99284) 
provided on July 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leneva (Q4100, J3590). 
 
You asked the Plan to pre-approve Leneva. 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 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 Leneva. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not show the enrollee with an ulcer as required by the criteria 
to justify use of this skin substitute product. Also, there is insufficient high-quality evidence found for use of 
this product for hyperkeratotic feet to justify this request. Therefore, Leneva will be considered not medically 
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 Leneva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leneva (Q4100, J3590).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR) (33285). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found that there is no documentation provided to suggest a history of 
unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. 
 
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 ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR) (33285).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on September 
14, 2023. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you went to the ER, and feel 
you should not have to pay both copayments after 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for an ambulance ride. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 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 copayment for an ambulance ride 
provided on September 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Omnigraf panel (81479) provided on August 22, 2023. 
 
You asked the Plan to pay for the Omnigraf panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
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 pay for the Omnigraf panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records included in this case file do not include documentation for the indication of this test. There is no documentation that supports the medical necessity of this test. 
 
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 Omnigraf panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the Omnigraf panel (81479) provided on August 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on August 14, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that the records provided support the method 
of transportation. The Plan denied your request. The Plan says there was no clear barrier to transport to the 
closest appropriate facility or use of ground transportation. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found the enrollee appears to have 
been stable enough to have been transported by ground. There was also a closer facility. The documentation 
does not note why this facility was unable to care for the enrollee. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for crowns (D2752) for tooth #8 and #9 provided on March 13, 2023. 
 
You asked the Plan to pay for the crowns. You say that that the crowns werent addressed under the original 
appeal. The Plan denied your request. The Plan says that the prior placement date is necessary in order to 
process this claim. 
 
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 says the prior placement date is required in order to 
process this claim. However, the medical records show this is an original crown placement and the Plan has not 
shown crowns were previously placed on tooth #8 and #9. Therefore, we decided that the Plan has to pay for 
crowns (D2752) for tooth #8 and #9 provided on March 13, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 8, 
2023, to July 7, 2023. 
 You asked the Plan to pay for SNF care. You say that the continued stay in a skilled nursing facility from June 
8, 2023, to July 7, 2023, was medically necessary. The Plan denied your request. The Plan says the continued 
stay in a skilled nursing facility from June 8, 2023, to July 7, 2023, was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from June 8, 2023, to July 7, 2023.