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

 
We decided that the Plan does not have to pre-approve radiation oncology consultation with an out-of-network 
(OON) tertiary care provider. 
 
You asked the Plan to pre-approve radiation oncology consultation with an OON tertiary care provider. You 
say that the provider they were previously approved to see does not work with the Plan and therefore is unable 
to treat them.  The Plan denied your request. The Plan says the enrollee can receive the requested services from 
the radiation oncologist they have already been authorized to see.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 radiation oncology consultation with an 
OON tertiary care provider. Our reviewer says that the criteria for coverage of OON care have not been met. 
Our physician reviewer found there are no compelling medical reasons offered in the case file to support the 
medical necessity of this enrollee receiving treatment out of network. There is no evidence in the case file that 
the out of network provider would provide a service that an in-network provider cannot.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation oncology consultation with an OON tertiary care provider have not 
been met. Therefore, we decided that the Plan does not have to pre-approve radiation oncology consultation 
with an out-of-network (OON) tertiary care provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria. The Plan 
denied your request. The Plan says the request 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 that there are no complex nursing or rehabilitation needs. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Syfovre. 
 
You asked the Plan to pre-approve Syfovre. You say that the requested Syfovre is medically necessary.  The 
Plan denied your request. The Plan says the requested Syfovre is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Syfovre. Our reviewer says that the 
requested Syfovre is not medically necessary.  Our physician reviewer found Syfovre is indicated for the 
treatment of geographic atrophy secondary to age-related macular degeneration. The documentation is 
insufficient to support that the enrollee in this case has geographic atrophy secondary to age-related macular 
degeneration requiring Syfovre. The documentation is insufficient to support that Syfovre would be safe and 
effective for the enrollee in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Syfovre have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Syfovre.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization of the knee (36247, 
36246). 
 
You asked the Plan to pre-approve geniculate artery embolization of the knee. You say that you want the Plan 
to approve the service. The Plan denied your request. The Plan says this is experimental/investigational and 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 geniculate artery embolization of the 
knee. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found genicular artery embolization is experimental for knee 
pain.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of geniculate artery embolization of the knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve geniculate artery embolization of the knee (36247, 36246).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. It appears the home ventilator is being used to treat obstructive sleep apnea, and this is not covered 
by Medicare. Consideration should be given to a repeat sleep titration study with adaptive support ventilation 
(ASV). 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (electric 
scooter) (K0801). 
 
You asked the Plan to pre-approve an electric scooter. The Plan denied your request. The Plan says an electric 
scooter would not increase the enrollee's independence and is therefore not considered medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if any power operated vehicle or power wheelchair is 
only for use outside the home, it will be denied as noncovered. 
 
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 electric scooter. Our reviewer says 
that the coverage criteria for an electric scooter are not met. Our physician reviewer found the enrollee is 
requesting a scooter for community mobility. The enrollee does not require the scooter for home management 
of activities of daily living (ADLs). Our reviewer also found that the scooter should be used when medically 
necessary to accomplish ADLs 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 an electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 1 heavy duty power operated vehicle (electric scooter) (K0801).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of 
service September 27, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761 and 99072. You say that these services are 
supported in the medical records. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. In addition, codes 94761 and 99072 are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The rules also say that for molecular 
diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine 
whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is 
assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87631 
have not been met. 
 
In addition, we find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. We have also confirmed that procedure code 94761 
has a status indicator of T on the Physician Fee Schedule and was billed with other payable services under the 
physician fee schedule for the same date by the same provider. This means that procedure code 94761 is not 
separately payable in this case. Based on this information, we decided that Medicare rules for coverage of 
codes 99072 and 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87631, 94761 and 99072 billed for date of service September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CA-125 and CEA testing (86304 and 82378) provided on 
January 25, 2023. 
 
You asked the Plan to pay for CA-125 and CEA testing. You say that these services were medically necessary 
and returned abnormal results which will help guide the enrollee's future treatment. The Plan denied your 
request. The Plan says these services were not provided for covered a covered diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that CEA testing may be medically necessary for follow-up of patients 
with colorectal carcinoma at treatment decision-making points. The rules also say that a CA-125 level may be 
obtained as part of the initial pre-operative work-up for women presenting with a suspicious pelvic mass to be 
used as a baseline for purposes of post-operative monitoring. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CA-125 and CEA testing have not been met. Specifically, the records indicate that the enrollee was 
undergoing evaluation for weight loss and shortness of breath. At the time of services, the enrollee had no 
diagnosis of cancer or suspicious masses and was not at a treatment decision making point. Therefore, we 
decided that the Plan does not have to pay for CA-125 and CEA testing (86304 and 82378) provided on 
January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that there is a medical need for this ventilator. The Plan 
denied your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal tract imaging (capsule endoscopy) 
(91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that you would like the Plan's decision to be 
reassessed. The Plan denied your request. The Plan says this request is not medically necessary because the 
records show the enrollee does not have evidence of ongoing gastrointestinal bleeding or any absorptive 
diseases of the small intestine. 
 
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 capsule endoscopy. Our reviewer says 
that the coverage criteria for a capsule endoscopy have not been met. Our physician reviewer found the 
provided records in this case do not document the enrollee has gastrointestinal bleeding, concern for neoplasm 
of the small bowel, a diagnosis of Crohn's disease, malabsorption syndrome, chronic diarrhea, or protein-losing 
enteropathy of obscure origin for which the procedure is indicated per the Local Coverage Determination 
(LCD) for Endoscopy by Capsule (L34081). 
 
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 capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a gastrointestinal tract imaging (capsule endoscopy) (91110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve bone marrow aspirate services. You say that the records provided support 
the need for the services which remain in dispute.  The Plan denied your request. The Plan says the medical 
necessity of the requested procedure has not been established after clinical review and per the peer-reviewed 
medical literature.  
 
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 bone marrow aspirate services. Our 
reviewer says that bone marrow aspirate services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bone marrow aspirate is experimental for use as bone graft in spinal fusion 
surgery. More research is needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate services.
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 appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for IRF care is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There 
is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive 
rehabilitation therapy 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 13, 2020, to 
July 14, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically 
necessary. The Plan denied your request. The Plan says observation level of care would have been more 
appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee did not have a significant history suggestive of needing a prolonged 
recovery related to this procedure. Therefore, it was not expected that the enrollee would require hospital care 
that would likely cross two midnights related to this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided July 13, 2020, to July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care (99221) provided on July 19, 2022. 
 
You asked the Plan to pay for the initial hospital care. You say that you would like this claim to be processed 
for payment. The Plan denied your request. The Plan says that the service was not authorized. 
 
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 pay for the initial hospital care. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was brought by the emergency medical services (EMS) to the emergency 
department (ED) on July 19, 2022, with increased shortness of breath. The enrollee was noted to be hypoxic to 
70s. Our reviewer found that in the ED the enrollee was treated with bilevel positive airway pressure (BiPAP), 
nebulizers and intravenous steroids. The enrollee was admitted with acute hypoxic respiratory failure due to 
chronic obstructive pulmonary disease exacerbation. Our physician reviewer also found that inpatient hospital 
level of care services were indicated. 
 
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 initial hospital care have been met. Therefore, we decided that the Plan has 
to pay for the initial hospital care (99221) provided on July 19, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found A home ventilator is not medically necessary. There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) 
retention. If that is present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
Average volume-assured pressure support (AVAPS) during sleep as an outpatient. This has not been tried and 
shown to fail. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).