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

 
We decided that the Plan does not have to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that the enrollee has tried and failed Prozac, Lexapro, 
Celexa, Pristiq, Effexor, Wellbutrin, Trintellix, Ablify, Cymbalta, sertraline, Paxil, amitrityline, nortriptyline, 
Seroquel, trazodone, lamotrigine, and Tegretol. You say that the enrollee has tried so many different 
medications that the Plan was going to be increasing her Abilify dosing in combination with the Spravato, since 
she isn't on the highest dose of Abilify.  The Plan denied your request. The Plan says the list of oral 
antidepressants that have been tried only included Paxil and Cymbalta. The Plan says that the requested drug is 
only FDA approved based on clinical trials in which there was an initiation of a new oral antidepressant.  
 
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 Spravato. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found Spravato is FDA-approved for the 
treatment of treatment-resistant depression in conjunction with an oral antidepressant. Provided records in this 
case do not document that the Spravato will be used in conjunction with an oral antidepressant. The use of 
Spravato for treatment-resistant depression without use of an oral antidepressant is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use of 
Spravato for treatment-resistant depression without use of an oral antidepressant does not meet Medicare 
criteria for safe and effective and otherwise reasonable and necessary 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 Spravato have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Spravato.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration based on the 
enrollee's clinical status and documented deterioration despite home health physical therapy and outpatient 
physical therapy. The Plan denied your request. The Plan says criteria for admission to the acute IRF setting 
have not been met.  
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for atrial fibrillation, sepsis, and colitis and was discharged home on May 19, 2023. There is 
ongoing weakness despite home health services. 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the WATS3D testing (88361, 88312, 88305, 88112) provided March 
11, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration for the 
standard surgical pathology performed by your laboratory known as WATS3D. The Plan denied your request. 
The Plan says that this service does not meet the medically necessary criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of Barrett's esophagus, with esophageal mucosal changes consistent 
with short-segment Barrett's esophagus. The indication for WATS3D testing was surveillance for malignancy 
due to personal history of Barrett's esophagus. The American Society for Gastrointestinal Endoscopy has made 
a conditional recommendation based on low quality evidence and suggests using WATS-3D in addition to 
white light endoscopy in patients with known or suspected Barrett's esophagus.  
 
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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for the WATS3D testing (88361, 88312, 88305, 88112) provided March 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from January 23, 2021, 
to January 28, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
DRG code should remain 280 as originally reported. The Plan denied your request. The Plan says there is not 
sufficient documentation to clinically validate diagnosis code G93.41. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code G93.41, defined as metabolic encephalopathy. 
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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the documentation does not support the diagnosis of metabolic 
encephalopathy for this admission. Our physician reviewer found that dizziness and balance issues were 
reported but the workup was essentially negative. The provided documentation revealed normal mental 
function and alertness, which precludes the enrollee from having any form of encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from January 23, 2021, to January 28, 2021, at the DRG originally 
billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9604 rendered on June 13, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code P9604 remains not supported. 
 
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 Healthcare Common Procedure Coding System (HCPCS) 
P9604 is "Travel allowance one way in connection with medically necessary laboratory specimen collection 
drawn from home bound or nursing home bound patient; prorated trip charge." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that code P9604 is not supported. The record does not state that a specimen was collected from a homebound or nursing home bound patient. The 
criteria to report this code has not been met. 
 
We looked at this coder'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 pay for procedure code P9604 rendered on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you need additional trips. The Plan 
denied your request. The Plan says your routine transportation benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223, 99409, & 99497 provided on 
November 13, 2022. 
 
You asked the Plan to pay for procedure codes 99223, 99409, & 99497. You say that these services were 
medically necessary. The Plan denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99223, 99409, & 99497 is not supported in the medical record. Specifically, the 
provided records do not support the codes billed. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 99223, 99409, & 99497 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99223, 99409, & 99497 provided on November 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 12, 2023 to 
February 10, 2023.  
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received. 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, no NOA was received by the plan. Without an NOA, the claim is not eligible for payment. 
Therefore, we decided that the Plan does not have to pay for home health services provided on January 12, 
2023 to February 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the colonography 
 
You asked the Plan to pre-approve the CT scan. You say that due to the enrollee's complications the services 
are medically necessary.  The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the criteria for approval is not met based on 
the appellant's provided records. The enrollee's evaluation has ruled out colonic obstructing tumors as well as 
significant extracolonic pathology. The rules for coverage are not satisfied. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the colonography
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urine polymerase chain reaction (PCR) test rendered on 
March 1, 2023. 
 
You asked the Plan to pay for the test. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this testing is considered unproven. 
 
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 test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this test does not currently have high quality evidence to support its use in this clinical situation. Standard of 
care is using urinalysis and culture. There was no indication that these tests would be inappropriate in this 
clinical situation. Therefore, this request for PCR testing will be considered 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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for a urine polymerase chain reaction (PCR) test rendered on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRTx5) 
(G6002, G6015). 
 
You asked the Plan to pre-approve IMRT. You say that the requested therapy is medically necessary. The Plan 
denied your request. The Plan says the requested service is not covered by Medicare or the health plan. Plan 
guidelines say there is no good evidence IMRT is needed or helpful for your condition. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the IMRT is not medically necessary for standard palliative courses of radiotherapy (XRT), 
especially in this case given the size of the disease which can easily be encompassed within small XRT fields. 
Other radiotherapy techniques like three-dimensional conformal radiotherapy (3DCRT) can be used in lieu of 
IMRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation therapy (IMRTx5) (G6002, G6015).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on September 01, 
2022, to September 30, 2022. 
 You asked the Plan to pay for the physical therapy services. You say that these services were medically 
necessary. 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 physical therapy 
services provided on September 01, 2022, to September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390), battery pack (E1356), back 
pack (A9270), and sales tax (S9999). 
 
You asked the Plan to pay for the oxygen concentrator and supplies. You say that the items should be covered. 
The Plan denied your request. The Plan says the items were purchased through a provider that is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390), battery 
pack (E1356), back pack (A9270), and sales tax (S9999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MyoPro orthosis (L8702). 
 
You asked the Plan to pay for the MyoPro orthosis. You say that the item was medically necessary. The Plan 
denied your request. The Plan says this item is considered 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 pay for the MyoPro orthosis. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the MyoPro Orthosis 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 patient's 
condition or in widespread use for this patient's condition based on scientific evidence. There is insufficient 
evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient. There 
is insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan 
does not have to pay for the MyoPro orthosis (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from November 9, 2022, 
to November 10, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says there was no documentation of a plan for an acute intervention, or any 
other treatment to support an inpatient bill.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee presented to the emergency department (ED) with worsening 
dysphagia. Examination and workup were essentially unremarkable. She was given fluids, IV medications and 
underwent esophagogastroduodenoscopy (EGD) with esophageal dilatation without complication. The vitals 
remained stable. Due to the enrollee being stable and not requiring complex treatment management, it was not 
expected that the enrollee would require hospital services that would have likely crossed 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services rendered from November 9, 2022, to November 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments (97813). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
  
 
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that there is a lack of 
documentation provided as required by the Medicare regulation regarding the duration of your back pain. For 
that reason, your request, at this time, is deemed not medically reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acupuncture treatments (97813).