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

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve a Sprint PNS. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says this is considered experimental and investigational. 
 
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 Sprint PNS. Our reviewer says that 
the requested Sprint PNS is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested device is considered experimental/investigational as additional research is 
needed. Therefore, the reviewer found that the requested device 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 a Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a kidney transplant evaluation. 
 
You asked the Plan to pre-approve a kidney transplant evaluation. You say that the facility is Medicare 
approved. The Plan denied your request. The Plan says that the facility is not Medicare-certified to do kidney 
transplants. 
 
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. The facility is found to be accredited by Medicare for kidney transplant and care. 
Based on the information submitted, we find nothing to substantiate the Plan's denial. Therefore, we decided 
that the Plan has to pre-approve a kidney transplant evaluation.  
 
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 laboratory services provided on November 03, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollees address is in another state. 
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 the laboratory services 
provided on November 03, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting 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 the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L5-S1 hemilaminectomy and discectomy (63030, 
69990). 
 
You asked the Plan to pre-approve an L5-S1 hemilaminectomy and discectomy. You say that this is medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of a 
hemilaminectomy in the setting of a normal neuromotor examination, no central canal stenosis, and no trial of 
physical therapy or exhaustion of conservative measures has not been demonstrated in the peer-reviewed 
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 an L5-S1 hemilaminectomy and 
discectomy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no recent physical therapy for back pain. There is 
no correlation between magnetic resonance imaging showing stenosis and physical examination showing 
neurological deficit. 
 
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 L5-S1 hemilaminectomy and discectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an L5-S1 hemilaminectomy and discectomy (63030, 
69990).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on August 31, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that the doctor provided services to the member 
in good faith and should be reimbursed for their services. The Plan denied your request. The Plan says virtual 
care out-of-network is not covered. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that virtual care (also referred to as telehealth services, 
virtual check-ins or eVisits) is not covered out-of-network. Based on this information, we decided that the 
Plans rules for coverage of the telehealth services have not been met. Therefore, we decided that the Plan does 
not have to pay for telehealth services provided on August 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from September 16, 2022, 
to October 12, 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 16, 2022. The NOA was not received by the Plan until April 10, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from September 16, 2022, to October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 12, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that  The Plan denied your request. The Plan 
says Current Procedural Terminology (CPT) code 87150-91 (1 Unit) remains not supported. This code is 
included in CPT code 87500; it cannot be separately reimbursed. In addition, the submitted documentation 
provided does not contain sufficient detail to support the billed charges. The records include laboratory results. 
However, the order/lab requisition does not include what organisms are represented by the billed code. 
Therefore, the billed code, modifier 91 and number of units cannot be verified. 
 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 the laboratory services have been met. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pigmented lesion assay (0089U) provided on May 10, 
2022.  
 
You asked the Plan to pay for the pigmented lesion assay. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing is experimental or investigational.  
 
The Plan follows 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 pigmented lesion assay. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that the assay in question is experimental or investigational. 
 
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 pigmented lesion assay have not been met. Therefore, we decided that the 
Plan does not have to pay for the pigmented lesion assay (0089U) provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement scooter (K0800). 
 
You asked the Plan to pre-approve a replacement scooter. The Plan denied your request. The Plan says based 
on Medicare guidelines, the replacement K0800 power operated vehicle requested does not meet the 
requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a capped 
rental item may be replaced in cases of loss or irreparable damage. 
 
 
 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 replacement scooter. Our reviewer 
says that this request is not reasonable and necessary. Our physician reviewer found the enrollee states the 
scooter is damaged. Our reviewer also found that the record is unclear whether the scooter is damaged beyond 
repair or not. 
 
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 replacement scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a replacement scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 23, 2022, to August 
26, 2022, billed with evaluation and management (EM) codes 99226, 99225, and 99217. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 29, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the practitioner services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
August 23, 2022, to August 26, 2022, billed with evaluation and management (EM) codes 99226, 99225, and 
99217.
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 requires IRF services to optimize their 
physical function. 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 the enrollees medical problems are stable and 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: Favorable

 
We decided that the Plan has to pre-approve carboplatin (J9045), pemetrexed (J9304), and nivolumab (J9299). 
 
You asked the Plan to pre-approve carboplatin, pemetrexed, and nivolumab. The Plan denied your request. The 
Plan says that medical necessity is not met for this combination of chemotherapy drugs, as nivolumab is not 
indicated without documentation of estimated glomerular filtration rate (eGFR) mutations or anaplastic 
lymphoma kinase (ALK) rearrangements status. 
 
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 carboplatin, pemetrexed, and 
nivolumab. Our reviewer says that this request is reasonable and necessary for this enrollee. Our physician 
reviewer found the FDA has approved nivolumab with platinum-doublet chemotherapy for adult patients with 
resectable non-small cell lung cancer in the neoadjuvant setting. Efficacy was evaluated in a randomized, open 
label trial in patients with resectable, histologically confirmed Stage IB or IIIA non-small cell lung cancer and 
measurable disease. The use of the requested drugs are not listed as not indicated, not supported, or not 
recommended in any of the compendia. The requested drug regimen is safe and effective for this 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 carboplatin, pemetrexed, and nivolumab have been met. Therefore, we decided 
that the Plan has to pre-approve carboplatin (J9045), pemetrexed (J9304), and nivolumab (J9299).  
 
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 pay for procedure code 99239 billed for October 31, 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 billed with inappropriate diagnosis codes. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with diagnosis codes that 
exclude each other. 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 procedure code 99239 billed 
for October 31, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's continued skilled nursing facility admission does not 
meet the requirements for approval. 
 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232 and 99231) provided from 
January 21, 2023, through January 23, 2023. 
  You asked the Plan to pay for subsequent hospital care (99232 and 99231). You say that you are resubmitting 
the claim with medical records and the claim should be reviewed for payment. The Plan denied your request. 
The Plan says diagnosis codes R55 and I95.1 should not be reported together.  
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, the claim was billed with diagnosis codes R55 and I95.1. Code I95.1 is an Excludes1 code under 
code R55, so these two diagnosis codes cannot be billed together. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care (99232 and 99231) have not been met. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care (99232 and 99231) provided from 
January 21, 2023, through January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued chiropractic manipulation treatments 
(98941).  
 
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 the service is not medically necessary as the requested services are 
considered maintenance therapy.  
 
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 the record indicates that you have back, hip, and shoulder pain. The records provided do not document 
the presence of subluxation either by physical examination or radiographic images. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the continued chiropractic manipulation treatments (98941).