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

 
We decided that the Plan does not have to pre-approve periurethral bulking (L8606), and endoscopic injection 
of implant material into the submucosal tissues of the urethra and/or bladder neck (51715). 
 
You asked the Plan to pre-approve the collagen implant. You say that the enrollee's abdominal leak point 
pressure was only slightly above the guideline value. You also say that that the enrollee's advanced age places 
them at risk for more complex surgical correction. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a collagen implant, and the procedure to inject it, is 
limited to female patients without urethral hypermobility and with abdominal leak point pressures of 100 cm 
H2O or less. 
 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 collagen implant. Our reviewer says 
that the requested collagen implant is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee's abdominal leak point pressure was greater than 100 cm H2O. 
Therefore, the reviewer found that the requested treatment 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 collagen implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve periurethral bulking (L8606), and endoscopic injection of implant material into 
the submucosal tissues of the urethra and/or bladder neck (51715).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Biocept Target Selector Circulating Tumor Cell (CTC) 
Assay Breast Cancer Profile provided on October 13, 2021, and billed with codes 88346, 88350, and 88377. 
 
You asked the Plan to pay for the Biocept Target Selector CTC Assay Breast Cancer Profile. You say that this 
testing was medically necessary. The Plan denied your request. The Plan says this testing should be billed with 
a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Biocept Target Selector CTC Assay 
Breast Cancer Profile have not been met. Therefore, we decided that the Plan does not have to pay for the Biocept Target Selector Circulating Tumor Cell (CTC) Assay Breast Cancer Profile provided on October 13, 
2021, and billed with codes 88346, 88350, and 88377.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an electronic knee and advanced 
foot (L5828, L5845, L5848, L5850, L5856, L5925). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the physician notes do not demonstrate a medical need for the microprocessor knee. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support medical necessity as the request for a microprocessor knee was 
premature at the time of the request.  At the time, staples were still in the stump and the enrollee had not yet 
seen the surgeon to evaluate the stump and readiness for a prosthetic. Additionally, there is no evidence in the medical records provided that the surgeon, after evaluating the patient, has requested the microprocessor 
knee.  From the records available, it appears that the advocate for this particular device is the device supplier. 
To be considered medically necessary, there would need to be documentation in the medical record from the 
surgeon specifically selecting this device and include documentation of a rationale. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an electronic knee and advanced foot (L5828, L5845, L5848, L5850, 
L5856, L5925).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high dose rate electronic brachytherapy, skin surface 
application, per fraction, includes basic dosimetry, when performed (0394T), therapeutic radiology simulation-
aided field setting; simple (77280) and therapeutic radiology simulation-aided field setting; complex (77290). 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says Medicare Guidance says Medicare can 
only cover medically necessary tests or treatments. 
 
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 electronic brachytherapy. 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 good data to consider this treatment medically necessary and a standard of 
care for the enrollee's condition. Treatments must be shown to be safe and effective for a condition for the 
treatments to be considered 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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a high dose rate electronic brachytherapy, skin surface application, per fraction, 
includes basic dosimetry, when performed (0394T), therapeutic radiology simulation-aided field setting; simple 
(77280) and therapeutic radiology simulation-aided field setting; complex (77290).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
23, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and 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.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 23, 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 a skilled nursing facility is not willing to take you 
because you were in a motorcycle accident and that is the reason you have been in the current hospital and 
cannot go back home on your own. The Plan denied your request. The Plan says your records do not show that 
your rehabilitation needs are complex. The Plan says that the services needed may be provided safely in a 
lower level of care.  
 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.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and an active compression garment (E1399). 
 
You asked the Plan to pre-approve a non-pneumatic compression controller with garment. You say that other 
therapies were tried and failed to aid the enrollee's chronic and progressive symptoms. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for approval of the requested device. 
 
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 non-pneumatic compression 
controller with garment. 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 evidence and/or documentation 
that the enrollee has tried a standard device that has failed to effectively treat her 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 a non-pneumatic compression controller with garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a non-pneumatic compression controller with 
sequential calibrated gradient pressure (K1024) and an active compression garment (E1399).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) provided on February 
4, 2023, billed with code 93042. 
 
You asked the Plan to pay for the ECG. You say that this claim was underpaid.  The Plan denied your request. 
The Plan says records were not submitted despite requests. As such, it cannot be determined that code 93042 
was reported for a diagnostic ECG. 
 
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. No medical records were submitted by the provider despite requests 
from the Plan. Without records, a determination on whether the criteria for coverage of code 93042 cannot be 
made. Based on this information, we decided that there is insufficient information in the record to determine if 
Medicare rules for coverage of the ECG have been met. Therefore, we decided that the Plan does not have to 
pay for the rhythm electrocardiogram (ECG) provided on February 4, 2023, billed with code 93042.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit (99203) provided on December 3, 
2022. 
 
You asked the Plan to pay for 99203. You say that the enrollee has not been seen by this provider or physician 
group within the last 3 years. The Plan denied your request. The Plan says the enrollee received a new patient 
office visit on March 12, 2020 which is less than 3 years prior to this date of service. 
 
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 99203 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low 
level of medical decision-making. When using time for code selection, 30 to 44 minutes is spent on the date of 
the encounter. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, the enrollee previously 
received a covered office visit from this physicians group practice on March 12, 2020. Therefore, the enrollee 
did not meet the definition of a new patient for the purposes of this visit and a new patient evaluation and 
management code should not be billed. Based on this information, we decided that Medicare rules for coverage 
of 99203 have not been met. Therefore, we decided that the Plan does not have to pay for a new patient office 
visit (99203) provided on December 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mvasi. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is responding well to this 
treatment combination. The Plan denied your request. The Plan says the requested treatment order of Mvasi 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 the medication. Our reviewer says that 
that the requested use of Mvasi is not FDA approved for the enrollees diagnosis. Our physician reviewer found 
that the use of Mvasi is also not supported by one of the major drug compendia or by clinical research.  
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Mvasi.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Mis 2 nonimplanted continuous glucose 
monitor (CGM) reader (A4239). 
 
You asked the Plan to pre-approve a Freestyle CGM reader. You say that the enrollee is unable to use her right 
side due to history of a stroke. This makes it challenging for her to use a traditional glucometer. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested CGM reader. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Freestyle CGM reader have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Mis 2 nonimplanted continuous glucose monitor (CGM) reader (A4239).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown (D2740) for tooth #11. We decided that the Plan does 
not have to pre-approve the pontic (D6245) for tooth #10.  
 You asked the Plan to pre-approve a crown (D2740) for tooth #11 and a pontic (D6245) for tooth #10. You say 
that the dental codes were approved last year, and you would like the services to be approved again. The Plan 
says that your benefit for the requested items or services has already been exhausted. 
 
We decided that the Plan has to pre-approve the crown (D2740) for tooth #11.  
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the crown (D2740) for tooth #11 was 
previously exhausted. Therefore, we decided that the Plan has to pre-approve the crown (D2740) for tooth #11.  
 
We also decided that the Plan does not have to pre-approve the pontic (D6245) for tooth #10. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved a pontic (D6245) for tooth #7, #8, #9, and #10 on June 20, 2023; therefore, your 
benefit for the pontic (D6245) for tooth #11 was exhausted on the date of approval of June 20, 2023. Therefore, 
we decided that the Plan does not have to pre-approve the pontic (D6245) for tooth #10. 
 
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: 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. The enrollee says that they are deemed incompetent and cannot 
care for themselves. The Plan denied your request. The Plan says admission into a skilled nursing facility is not 
medically necessary. 
 
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 pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been at least three months of pain. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the LCD requires that three diagnosis sacroiliac joint tests be documented. Only one is documented 
positive here. Additionally, the use of steroids in the presence of sacral fractures is very controversial. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
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 still require extensive hands-on assistance from 
the nursing and therapy staff. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an IRF.  
 
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. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 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.