Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.  The requested service cannot be 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening ultrasound of abdominal aorta for aneurysm 
(AAA) provided on February 10, 2023. 
 
You asked the Plan to pay for the screening ultrasound of AAA. You say that the service performed was 
appropriate with the billed diagnosis code. The Plan denied your request. The Plan says the service was not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a one-time ultrasound screening for abdominal 
aortic aneurysm (AAA) for beneficiaries may be covered when certain criteria have been met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the screening ultrasound of AAA have not been met. Specifically, the file does not support that the 
enrollee has a family history of abdominal aortic aneurysm, has a history of smoking at least 100 cigarettes in 
their lifetime, or manifests other risk factors in a beneficiary category recommended for screening by the 
United States Preventive Services Task Force regarding AAA. Therefore, we decided that the Plan does not 
have to pay for the screening ultrasound of abdominal aorta for aneurysm (AAA) provided on February 10, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that an epidural 
steroid injection is not medically necessary.  
 
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 injection. Our reviewer says that the 
enrollee does meet the coverage criteria. Our physician reviewer found that the enrollee has cervical 
radiculopathy and their symptoms support C6-C7 radiculopathy. The enrollee also has multi-level degenerative 
changes with neural foramen stenosis at C6-C7. Therefore, the requested epidural steroid injection is 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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection.  
 
 
 
 
 
 
 
 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 25 fractions of rotational arc therapy/volumetric 
modulated arc therapy (VMAT) intensity-modulated radiation therapy (IMRT) services. 
 
You asked the Plan to pre-approve 25 fractions of rotational arc therapy/VMAT. You say that the requested 25 
fractions of rotational arc therapy/VMAT IMRT. You say that this would be 5 additional fractions in phase 1, 5 
fractions for phase 2, and 15 fractions for phase 3. The Plan denied your request. The Plan says the request for 
25 doses exceeds the limit of course treatment. 
 
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 25 fractions of rotational arc 
therapy/VMAT. Our reviewer says that the requested 25 fractions of rotational arc therapy/VMAT are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the guidelines emphasize minimizing toxicity from radiotherapy and not dose escalating beyond accepted regimens (55 grays 
(Gy) in 20 fractions or 6 Gy in 6 fractions). The reviewer found that the delivery of more than 20 fractions of 
radiation in the metastatic setting is outside of the standard of care. The reviewer also found that the provided 
documentation does not support the need for going outside of the standard of care. Therefore, the reviewer 
found that the requested treatment 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 25 fractions of rotational arc therapy/VMAT have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 25 fractions of rotational arc therapy/volumetric modulated 
arc therapy (VMAT) intensity-modulated radiation therapy (IMRT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics-porcelain/ceramic (D6245) for tooth #5 and #8 
and retainer crowns (D6740) for tooth #4, #6, #7, #9 and #10. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee strongly declines a partial 
denture. The enrollee reports having a partial denture before which affected their speech, and they were not 
able to eat properly with it. The Plan denied your request. The Plan says the submitted narrative fails to indicate 
or support any specific physical or psychological condition that preclude the use of a removable prosthesis. 
 
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 the rules for coverage of the pontics and retainer crown have been 
met. Specifically, coverage for the pontics and retainer crowns cannot be considered until medical records and 
x-rays are submitted. Therefore, we decided that the Plan does not have to pre-approve pontics-
porcelain/ceramic (D6245) for tooth #5 and #8 and retainer crowns (D6740) for tooth #4, #6, #7, #9 and #10.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a dermatologist. 
 
You asked the Plan to pre-approve the specialist visit . You say that you are due for a skin check to make sure 
you do not have skin cancer or any other alarming medical conditions. You say that this is for preventive 
purposes. You also say that you do not want to wait until it is too late for an alarming medical issue. The Plan 
denied your request. The Plan says the requested service 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 the specialist visit. Our reviewer says 
that the requested specialist visit is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that you require a preventive skin check for a 
cancer screening. The reviewer also found that the documentation does not include any evidence that the cyst is 
not benign. Therefore, the reviewer found that the requested specialist visit 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 specialist visit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an office visit with a dermatologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for  the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve for  the orthotic device. You say that the enrollee has been referred by the 
family nurse practitioner for myoelectric orthotic restoration using the MyoPro Motion G. The Plan denied 
your request. The Plan says this item is considered experimental and investigational. There is insufficient 
evidence of its safety and effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve for  the MyoPro Motion G orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve ablation of malignant prostate tissue, transrectal, with high 
intensity-focused ultrasound (HIFU), including ultrasound guidance (55880). 
 
You asked the Plan to pre-approve HIFU treatment. You say that you are requesting reconsideration of the 
denied authorization due to medical necessity. The Plan denied your request. The Plan says that the request is 
not medically necessary because the enrollee does not have a biopsy-proven recurrence of cancer in the prostate 
after radiation therapy. 
 
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 HIFU treatment. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has clinical stage T1c, Gleason's grade 3+3 adenocarcinoma of the prostate with a 
baseline PSA 9.0 ng/mL at the time of initial diagnosis in 2018. He has been on active surveillance but chose to 
have robotic prostatectomy in June 2022, due to increasing PSA (14.76 ng/mL). The robotic prostatectomy was 
aborted due to mesh related adhesions. High intensity-focused ultrasound (HIFU) is considered medically 
reasonable and necessary in this case. HIFU treatment of the prostate is neither experimental nor 
investigational. HIFU was FDA approved for prostate gland ablation October 9, 2015.  HIFU of the prostate 
(CPT 55880) has Medicare coverage as of July 1, 2017. More than 100 clinical studies have demonstrated 
treatment efficacy that is comparable to surgery or radiation but with a much lower risk of side effects such as 
impotence, urinary incontinence, and bowel injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIFU treatment have been met. Therefore, we decided that the Plan has to pre-
approve ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), 
including ultrasound guidance (55880).  
 
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 pay for the genetic testing provided on April 12, 2022, billed with 
codes 81455, 81301, 81194 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. 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 
April 12, 2022, billed with codes 81455, 81301, 81194 and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae breast cancer (BRCA) 1 and 2 gene analysis 
(81162) provided January 6, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee' physician ordered the Invitae 
Hereditary Cancer test due to the enrollee being personally affected by breast and ovarian cancer.  The Plan 
denied your request. The Plan says the Invitae BRCA 1 and 2 panel is listed as noncovered by Medicare per 
Diagnostics Exchange (DEX). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the Invitae breast cancer (BRCA) 1 and 2 gene analysis (81162) provided January 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 15822-RT and 15822-LT billed for date of 
service September 22, 2022. 
 You asked the Plan to pay for procedure codes 15822-RT and 15822-LT. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 15822-RT and 15822-LT is bundled 
into payment for code 67904. 
 
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, we have confirmed that codes 
15822-RT and 15822-LT are column II codes to column I code 67904. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 15822-RT and 15822-LT 
billed for date of service September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on November 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as 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 claim was not billed with a device code for code 27428. As such, the claim denied and returned 
OCE edit 92. This edit denies the entire claim. 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 the 
outpatient services provided on November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric step stool (A9270). 
 
You asked the Plan to pre-approve a step stool. You say that you have been unable to sleep in your bed. You 
feel a step stool with a handrail will help you get into your bed and help you sleep. The Plan denied your 
request. The Plan says the stool considered a comfort and convenience item and not primarily medical 
treatment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a bariatric step stool (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has chronic low 
back pain and lumbar radiculopathy. Although the enrollee has had 70-80% pain relief in 2 months, the LCD 
requires at least 50% pain relief for 3 months, Therefore, the request is 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), and a core build-up (D2950) for teeth 
#7 and #10. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted with the approval of D2740 and D2950 for teeth #6, #8 and #9. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740), and a 
core build-up (D2950) for teeth #7 and #10.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the computed tomography, heart, without contrast material, with 
quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the criteria for approval have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our physician reviewer 
found Centers for Medicare & Medicaid Services (CMS) allows for computed tomography (CT) coronary 
calcium scoring in patients in whom the atherosclerotic cardiovascular disease (ASCVD) score is between 5 
and 19.9 percent. According to the submitted records this enrollee's risk score is 10.9 percent which qualifies 
the enrollee for the requested CT coronary calcium scoring. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve the computed tomography, heart, without contrast material, with quantitative evaluation of coronary 
calcium (75571).  
 
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.