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

 
We decided that the Plan does not have to pay for a duplex scan of lower extremity arteries provided on 
September 21, 2022. 
 
You asked the Plan to pay for a duplex scan of lower extremity arteries. You say that prior authorization is not 
required for this service. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a duplex scan of lower 
extremity arteries provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you need this benefit. The Plan denied your 
request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery (64636, 64635) provided on October 
9, 2018. 
 
You asked the Plan to pay for the outpatient surgery. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient surgery was not filed until May 11, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the outpatient surgery (64636, 64635) provided on October 9, 
2018.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug testing (80307) provided on May 26, 2022. 
 
You asked the Plan to pay for presumptive drug testing. You say that this service was necessary. The Plan 
denied your request. The Plan says this service is denied. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 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 Medicare rules for coverage of presumptive drug testing have been 
met. Specifically, no results of any presumptive drug tests were provided to support these services were 
provided as billed. Therefore, we decided that the Plan does not have to pay for presumptive drug testing 
(80307) provided on May 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that this would provide you with the care needed. The 
Plan denied your request. The Plan says the services you require can safely be received at a different setting 
such as home with outpatient treatment. 
 
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 pre-approve 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Zirabev and Fluorouracil 5-FU. 
 
You asked the Plan to pre-approve Zirabev and Fluorouracil 5-FU. You say that this is reasonable because the 
enrollee has recent progression. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Zirabev and Fluorouracil 5-FU. Our 
reviewer says that the enrollee does not meet criteria for this drug combination. Our physician reviewer found 
Zirabev and Fluorouracil 5-FU are not Food & Drug Administration (FDA) approved for the enrollee's 
diagnosis. There is not enough information to see what is being used for treatment currently or for how long. The requested use is not supported by one of the major drug compendia or by clinical research appearing in a 
Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zirabev and Fluorouracil 5-FU have not been met. Therefore, we decided that 
the Plan does not have to pre-approve use of Zirabev and Fluorouracil 5-FU.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you have an open wound on your buttock, 
are diabetic, had polio and have an amputated leg. You also say you have no help at home and SNF services 
will help you recover faster. The Plan denied your request. The Plan says you have exhausted the 100-day 
benefit for inpatient SNF care for the current benefit period as of May 16, 2023. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from January 4, 2023, to  
May 16, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates of service September 
15, 2022, to September 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code accurately reflects the treatment 
provided. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. 
 We find that CPT code 99233 is not supported in the medical record. The records show that the enrollee was 
seen for pain and a wound. The enrollee was stable and denied chest pain, nausea, or shortness of breath. The 
records do not show that medical decision making of high complexity or a detailed interval history was 
provided. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99233 billed for 
dates of service September 15, 2022, to September 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair (A9900, E0627). 
 
You asked the Plan to pre-approve a lift chair. You say that the items are medically necessary. The Plan denied 
your request. The Plan says the items are not medically necessary.  
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 lift chair. Our reviewer says that you 
do not need these items. Our physician reviewer found you can ambulate independently and are independent 
with transfers from various surfaces with good safety technique. 
 
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 lift chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lift chair (A9900, E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that the services should be reimbursed. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary, you can safely receive the services you need in 
other settings, for example: a skilled nursing 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested SNF service is not supported based on 
the records received. 
 
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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. The Plan denied your request. The Plan says the drug is not being 
prescribed for a medically accepted indication. 
 
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 Vabysmo. Our physician reviewer 
found that the enrollee has a diagnosis of retinal vein occlusion with macular edema. The FDA has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements 
of the coverage criteria 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve radiofrequnecy ablation. 
 
You asked the Plan to pre-approve a genicular nerve radiofrequnecy ablation. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 genicular nerve radiofrequnecy 
ablation. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, 
reasonable, comprehensive, less invasive conservative care measures is not evident. Ongoing home exercises or 
specific treatment modalities that have been trialed since the recurrence of pain is not clearly documented. 
Additionally, there is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of these procedures for this enrollee as discussed above. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested injections in this clinical 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 a genicular nerve radiofrequnecy ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a genicular nerve radiofrequnecy ablation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are very weak and need more time to get 
stronger so you can have a safe discharge home. The Plan denied your request. The Plan says your condition 
does not meet requirements for admission to a SNF. 
 
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 pre-approve 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 pre-approve SNF care.
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 continues to need medical oversight and 
continued therapy following a hip fracture. The Plan denied your request. The Plan says the records do not 
show that the enrollee needs an extensive team for their therapies. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 30, 2022, to 
September 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with required TOB code 
032x. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
August 30, 2022, to September 3, 2022.