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

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography procedure (93307). 
 
You asked the Plan to pre-approve a transthoracic echocardiography. You say that a transthoracic 
echocardiography is a medical necessity for the enrollee. The Plan denied your request. The Plan says a 
transthoracic echocardiography 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 pre-approve a transthoracic echocardiography. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the request is for a transthoracic echocardiography in an enrollee with 
physical exam showing no cardiac abnormalities on auscultation and recently completed stress test. Guidelines 
do not support a need for a transthoracic echocardiography in this setting.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiography procedure (93307).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the member does not have clinical conditions that cannot be appropriately 
treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage. 
Therefore, the denial is upheld. The plan will continue to cover medically necessary acute and 
critical care at the current facility until the member's condition is stable for transfer to an alternate level of care. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental visit (D9430). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the dental visit not covered by the Plan. 

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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
dental visit (D9430).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95938 and 95861 billed for date of service 
March 9, 2023. 
 
You asked the Plan to pay for procedure codes 95938 and 95861. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says these codes are included in the facility payment and is not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 95938 and 95861. This means there is 
both a professional and technical component for the CPT codes. In this case, an appropriate modifier to indicate 
the professional component has not been billed with CPT codes 95938 and 95861. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 95938 and 95861 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95938 and 95861 billed for date 
of service March 9, 2023.
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. The Plan denied your request. The Plan says the records show the 
enrollee does not have the ability to participate in 3 hours of intense physical therapy for 5 days per week. 
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 the enrollee's 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical access to implant body (D6011) and an 
implant abutment (D6051) for tooth #10. 
  
You asked the Plan to pre-approve the dental services. You say that you had your tooth extracted and your 
coverage should be 100% for the implant. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the surgical access to implant body and an implant abutment 
are not covered by the Plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical access to implant body (D6011) and an implant abutment (D6051) for tooth #10.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services (73630, Q0092, R0070) provided on 
November 18, 2022. 
 
You asked the Plan to pay for the portable x-ray services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the records do not support the billed 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. 
 
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 portable x-ray services. Our reviewer says that the 
records do not support the billed services.  
 Our reviewer found the medical records provided do not include sufficient documentation to validate that 
Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient (R0070) was performed. The medical records provided does not include sufficient 
documentation to validate that Set-up portable X-ray equipment (Q0092) was performed. The medical records 
submitted indicate  Radiologic examination, foot; complete, 3 views was performed on the left side, but only 2 
views were performed on the right side, therefore the use of a 50 modifier is not appropriate for code 73630. 
 
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 portable x-ray services have not been met. Therefore, we decided that the 
Plan does not have to pay for portable x-ray services (73630, Q0092, R0070) provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 06, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 office visit provided 
on January 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel provided on June 
30, 2022.  
 
You asked the Plan to pay for a targeted genomic sequence analysis panel. You say that the molecular testing 
in dispute was requested directly from the treating physician who makes the professional determination of 
diagnosis and medical necessity to successfully treat the patient. You say that the medical records support that 
the testing in dispute was medically necessary.  The Plan denied your request. The Plan says Next Generation 
Sequencing (NGS) testing is not covered as part of an anemia work-up.  
 
The Plan follows Medicare rules. Medicare rules say that NGS testing is only covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
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 a targeted genomic sequence analysis panel. 
Our reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the enrollee 
is a 75-year-old female with MDS-EB2. Biopsy showed normocellular marrow with dyspoiesis and without increased blasts. A targeted genomic sequence analysis panel (GTC-Hematology Profile) was provided on June 
30, 2022. The provided records did not show an inadequate or failed cytogenetic assessment nor was there 
evidence of a recurrent/relapsed, metastatic, or stage III or IV cancer or any other indication to justify this 
testing based on the provided NCD which has not been met.  
 
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 targeted genomic sequence analysis panel have not been met. Therefore, we 
decided that the Plan does not have to pay for a targeted genomic sequence analysis panel provided on June 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services (0117U) provided on November 
22, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that the requested laboratory testing services were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 laboratory testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested laboratory testing is an experimental/investigational algorithm that is not part of any 
clinical-practice guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory testing services (0117U) provided on November 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone and has no help for activities 
of daily living. The enrollee requires therapy in a SNF setting. The Plan denied your request. The Plan says the 
request 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 that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that Prolia is the only drug that is approved and proven to 
treat your condition. 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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found that there is no indication that you have tried and failed 
the required drugs oral bisphosphonate or an injectable bisphosphonate. Also, there is no indication that the 
Plan's required drugs would likely be less effective or likely have adverse effects on you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery services (22600, 22610, 22614, 22843). 
 
You asked the Plan to pre-approve spinal surgery services. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the surgical plan is unclear. 
 
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 spinal surgery services. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the provided medical records do not show the surgical plan details. It is unclear 
what levels are to be operated on and why. There is no instability documented. More information is needed to 
demonstrate the medical necessity of the requested services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal surgery services (22600, 22610, 22614, 22843).
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pay for the remaining charges over the maximum out-of-pocket amount of 
$3,850. We decided that the Plan does not have to waive the copayment of $2,632 and any difference between 
that and the full out-of-pocket maximum of $3,850. 
 
You asked the Plan to pay for PT services provided from February 8, 2022, to April 14, 2022. You say that you 
are requesting a reimbursement for payments above your maximum out-of-pocket expenses. The Plan says that 
the amount the enrollee paid out-of-pocket does not apply to the maximum out-of-pocket and the copayment 
applied is correct. 
 
We decided that the Plan has to pay for the remaining charges over the maximum out-of-pocket amount 
of $3,850.  
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). The Plan has not provided the necessary documentation to justify the 
denial for the PT services rendered. The plan is responsible to provide the claim information for the dates in 
question, as the provider is in-network and an agent of the Plan. In addition, the EOC does not exclude 
coverage for PT services rendered during a skilled nursing facility (SNF) stay. Therefore, we decided that the 
Plan has to pay for the remaining charges over the maximum out-of-pocket amount of $3,850.  
 
We also decided that the Plan does not have to waive the copayment of $2,632 and any difference 
between that and the full out-of-pocket maximum of $3,850. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $0 
copayment for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF services. Therefore, we 
decided that the Plan does not have to waive the copayment of $2,632 and any difference between that and the 
full out-of-pocket maximum of $3,850. 
 
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. You say that you are unable to care for yourself and believe that 
SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet the criteria 
for admission to a SNF.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the human leukocyte antigens (HLA) testing received on 
February 7, 2023. 
 
You asked the Plan to pay for the HLA testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services received are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that HLA testing is only covered for certain indications. 
 
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 HLA testing. Our reviewer says that the 
services received are not medically reasonable or necessary. Our physician reviewer found your past medical history includes chronic constipation, poor memory, diabetes, and musculoskeletal pain. There is no specific 
clinical rationale for the requested HLA testing. In this case, the records show that the enrollee has not 
undergone baseline serologic testing or any diagnostic studies. HLA testing is not appropriate as a screening 
test. Therefore, you did not meet criteria for the services rendered. 
 
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 HLA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the human leukocyte antigens (HLA) testing received on February 7, 2023.