Persius/hicric huggingface dataset:
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 the enrollee had a hip replacement, and needs intense 
therapy because the hospital is ready to discharge the enrollee and they need to go to the next level of care. You 
also say that the enrollee needs this level of care that the skilled nursing facility cannot provide them. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the 
requirements for approval.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Our reviewer also found that the enrollee's 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sarclisa. 
 
You asked the Plan to pre-approve Sarclisa. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Sarclisa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
requested use of Sarclisa is not FDA-approved for the enrollees diagnosis. Its is not use supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sarclisa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Sarclisa.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 CDx testing (81479) provided on July 2, 2023. 
 
You asked the Plan to pay for the Guardant360 CDx testing. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the claim for this molecular 
pathology testing included a unique identifier code that is not associated with CPT code 81479 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. The rules also say that if one laboratory 
procedure evaluates multiple genes using a next generation sequencing (NGS) procedure, the laboratory shall 
report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, 
multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. Review of the claim does show that the required unique identifier 
was reported. Additionally, this was an NGS panel that was billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Guardant360 CDx testing have been 
met. Therefore, we decided that the Plan has to pay for the Guardant360 CDx testing (81479) provided on July 
2, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with diagnosis codes C56.1 and 
C56.2 provided on May 2, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were billed with one or 
more diagnosis codes that were inappropriately coded. Medicare rules say that some ICD-10-CM codes 
indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate 
to report left and right when a more specific bilateral diagnosis code is available. Therefore, we decided that 
the Plan does not have to pay for the laboratory services billed with diagnosis codes C56.1 and C56.2 provided 
on May 2, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 8, 2023, to June 19, 
2023. 
 You asked the Plan to pay for the home health services. You say that the enrollee was not on hospice for the 
dates of service in question. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 6, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for home health services 
provided on June 8, 2023, to June 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services. You say that the out-of-network (OON) provider 
is closer to your home and provides better care. The Plan denied your request. The Plan says these services can 
be provided to you by an in-network (INN) provider that is located closer to your home. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 12, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee's hospice was revoked on this 
date. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on February 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder orthosis (L3960) and ultraviolet (UV) wand 
(E0691), provided on June 30, 2023. 
 
You asked the Plan to pay for a shoulder orthosis and UV wand. You say that the items should be covered. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. There is no indication these items were ordered or needed in the 
medical records submitted. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a shoulder 
orthosis (L3960) and ultraviolet (UV) wand (E0691), provided on June 30, 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. You say that you need acute inpatient rehabilitation to monitor 
your oxygen levels and to help you regain is your strength through one on one 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 complexity of your medical, rehabilitation, and nursing needs (combined 
complexity) does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to 
rehabilitative care. Our reviewer also found that your rehabilitation needs can be safely provided in an alternate 
and low intensity setting such as in-home with 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 22, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 a $325 
copayment for ambulance services.  
 
You have been asked to pay a $325 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on June 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET/CT scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found 5-HIAA level is pending. No other 
serological markers such as gastrin have been drawn. Medical necessity for the ordered PET/CT has not yet 
been established. 
 
   
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) scan (78815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vivistim Paired Vagus Nerve Stimulation (VNS) 
System (64568). 
 
You asked the Plan to pre-approve the VNS systerm. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is currently 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 pre-approve the VNS systerm. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this item is currently experimental. 
 
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 VNS systerm have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Vivistim Paired Vagus Nerve Stimulation (VNS) System (64568).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service June 5, 2023. 
 You asked the Plan to pay for the billed services. You say that the medical records support the critical care 
performed. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service).  
 
We find that CPT code 99292 is not supported in the medical record. The medical records show that 40 
minutes of critical care were provided on the date of service at issue, which was paid under code 99291. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99292 billed for date of service 
June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95938-TC, 95939-TC, 95861-TC, and 
95955-TC billed for date of service January 17, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says this code is 
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-TC, 95939-TC, 95861-TC, and 
95955-TC. The services at issue were provided via arrangement of the facility. Payment for this service would 
have been included under the facility claim. Payment to you for this service is the responsibility of the facility.  
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 95938-TC, 95939-TC, 95861-TC, and 95955-
TC billed for date of service January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE) (36247). 
 
You asked the Plan to pre-approve PAE. You say that the services are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria 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 pre-approve PAE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found prostate artery embolization (PAE) is not medically reasonable and necessary in this case. 
Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign 
prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve prostate artery embolization (PAE) (36247).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraoral  comprehensive series of radiographic 
images (D0210), comprehensive oral evaluation - new or established patient (D0150), and prophylaxis - adult 
(D1110). 
 
You asked the Plan to pre-approve the dental services. You say that you have been with the dental provider for 
years and do not wish to change. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental benefits.  
 
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. 
 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve an intraoral 
 comprehensive series of radiographic images (D0210), comprehensive oral evaluation - new or established 
patient (D0150), and prophylaxis - adult (D1110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the initial evaluation (99203), the reevaluation (99213), 
the chiropractic manipulation (98942x17), the laser therapy (97026x14), and the hydrotherapy (99999x13) 
provided from February 7, 2023, to March 14, 2023. 
 
You asked the Plan to pay more for the chiropractic services. You say that you would like to be reimbursed for 
the services. You say you included the appropriate procedure codes. The Plan denied your request. The Plan 
says the chiropractic manipulation benefit limit has been reached. Also, the Plan paid for the initial evaluation 
and the reevaluation. The laser therapy and the hydrotherapy are not covered services. 
 
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 Plan offers up to ten routine chiropractic 
services per year. 
 
 The records show that the service hydrotherapy and the laser therapy are not covered benefits. The Plan paid 
for ten chiropractic manipulation services between January 31, 2023, to February 27, 2023, which exhausted 
the benefit. Please note, the Plan paid their portion of the initial evaluation and the reevaluation. 
 
Therefore, we decided that the Plan does not have to pay more for the initial evaluation (99203), the 
reevaluation (99213), the chiropractic manipulation (98942x17), the laser therapy (97026x14), and the 
hydrotherapy (99999x13) provided from February 7, 2023, to March 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the spine. 
 
You asked the Plan to pre-approve an MRI of the spine. The Plan denied your request. The Plan says an MRI 
of the spine is not medically necessary.  
 
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 spine. Our reviewer says 
that an MRI of the spine is not medically necessary.  Our physician reviewer found that there was no recent 
physical therapy done for the back pain. Therefore, the request is 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 an MRI of the spine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the spine.