Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to pre-approve 10 fractions of stereotactic body radiation therapy (SBRT).. You say that 
SBRT is the standard of care in the enrollee's clinical circumstances. The Plan says that this is not medically 
necessary. 
 
We decided that the Plan has to pre-approve 5 fractions of SBRT.  
 
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 SBRT. Our reviewer says that the 
enrollee meets criteria for 5 fractions of SBRT. Our physician reviewer found the enrollee has node-negative 
non small cell lung cancer (NSCLC) for which SBRT was offered. SBRT delivering high fractional doses in 1 
to 5 fractions is an established approach for discrete lesions from cancer. There is abundant data on the use of 
SBRT for this condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 5 
fractions of SBRT.  
 
We also decided that the Plan does not have to pre-approve an additional 5 fractions of SBRT. 
 
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 5 fractions of SBRT. Our reviewer says 
that the enrollee does not meet criteria for an additional 5 fractions of SBRT beyond what was approved. Our 
physician reviewer found it is unclear why 10 fractions were requested which may be a clerical error. 5 
fractions of SBRT is an accepted standard of care and reflects what was prescribed to the enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 additional fractions of SBRT have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an additional 5 fractions of SBRT. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the hip (73721). 
 
You asked the Plan to pre-approve an MRI of the hip. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the hip. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the request for an MRI of the left hip is 
medically necessary due to the prior steroid injections of the sacroiliac (SI) joints you have had with your 
rheumatoid arthritis, persistent and severe left hip 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 an MRI of the hip have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the hip (73721).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service December 29, 
2022, to January 27, 2022. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the NOA was 
not received timely.  
 
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 December 29, 2022. The NOA was not received by the Plan until February 
22, 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 care billed for 
dates of service December 29, 2022, to January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health treatment services.

You asked the Plan to pre-approve behavioral health treatment services. You say that you have learned a lot about trauma in your life from this provider. Not being able to work with this provider would hurt you in treating trauma. The Plan denied your request. The Plan says there are in-network doctors within your geographical area that can provide services in questions. they have made multiple exceptions over the last year to help you transition to an in-network doctor.

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 behavioral health treatment services. Our reviewer says that the service is not medically necessary. Our physician reviewer found that based on review the records provided, you were given a one-year exception and an additional 12 visits extension to transition to an in-network provider. You are not showing any emergent symptoms which would require immediate treatment outside of the network.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of behavioral health treatment services have not been met. Therefore, we decided that the Plan does not have to pre-approve behavioral health treatment services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine lab panel provided on April 8, 2022. 
 
You asked the Plan to pay for the lab panel. The Plan denied your request. The Plan says this testing 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 pay for the lab panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large 
multiplex polymerase chain reaction (PCR) urinary tract infection panel tests. 
 
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 lab panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the urine lab panel provided on April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 14, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that you disagree with the Plan's denial. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device. 
 
You asked the Plan to pre-approve the requested device. You say that the device provides functional restoration 
of strength and range of motion. The Plan denied your request. The Plan says the device is unproven 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 the requested device. Our physician 
reviewer found that the enrollee had a stroke in 2002, which resulted in left upper extremity partial paralysis. 
The enrollee has tried and failed physical and occupational therapy. The MyoPro device is not known to be 
effective, based on scientific evidence, professional standards and expert opinion, in improving health 
outcomes.  The MyoPro is not the standard of care for this enrollees condition or in widespread use for this enrollees 
condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro device 
will improve the long-term outcomes for this enrollee. There is insufficient evidence in the literature that this 
device will increase participation in bimanual activities. Therefore, the device 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro orthotic device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 27, 2023. 
 
You asked the Plan to pay for the lab panel. 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 a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes, and not one 
unit of one code as required by LCA A58726. Based on this information, we decided that Medicare rules for 
coverage of the lab panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab panel provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and diagnostic radiology provided on  
April 20, 2023. 
 
You asked the Plan to pay for the office visit and diagnostic radiology. You say that the services should be 
covered because this doctor is in a surgical center. The Plan denied your request. The Plan says this service is 
not covered when it is billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit and diagnostic radiology provided on April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 13, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The billed PrismRA test is not a covered test as it is not registered on 
the DEX Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided on June 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you believe this should be covered. 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 Plan's 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 on date of service May 16, 2023. Therefore, 
we decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided on June 6, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vegzelma. 
 You asked the Plan to pre-approve Vegzelma. You say that the enrollee cannot afford the 20% copay for 
Zirabev. You say that there is a free drug assistance program that is available for Vegzelma through the drug 
company. The Plan denied your request. The Plan says that the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vegzelma. Our reviewer says that 
Vegzelma is not medically necessary. Our physician reviewer found that the enrollee has metastatic high grade 
serous adenocarcinoma primary peritoneal, and the medication is a new start. However, there is no indication 
that the enrollee has tried and failed the Plan's preferred step one alternative. Also, there is no indication that 
the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one 
alternative. Therefore, the elements of the coverage criteria are not satisfied, and 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 Vegzelma have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vegzelma.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 4, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on May 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for the requested LTACH admission. The Plan denied your request. The Plan says the enrollee does not 
meet the medical LTACH level of care guidelines for admission to the long term acute care hospital.  
 
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 documentation does not support that the enrollee has need for complex medical 
treatment in the LTACH. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupro. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Neupro.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 say that two physiatrist recommend inpatient 
rehabilitation. You also say that the patient is medically ready for inpatient rehabilitation. The Plan denied your 
request. The Plan says based on the available information, admission to an IRF is not reasonable and 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 the patient does not require the intensity of services provided at an IRF.  Specifically, 
the patient is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation.  Our reviewer also found that the patients care needs can be met at a lower 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 Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee as low back and neck pain 
that has continued for five years. Conservative treatment has been attempted with no success. The Plan denied 
your request. The Plan says medical studies have not proven this procedure helps with the enrollee's condition. 
There are other proven methods that could help. 
 
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 Intracept procedure. 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 magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or stenosis. The cause of pain is also not clear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.