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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the scan is being recommended for the enrollee's 
symptoms. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the enrollee was noted to have had 
memory problems on exam. However, there was no indication that the enrollee was suspected of having either 
Alzheimers disease of frontotemporal dementia, let alone both. 
 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
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 you do not meet the 
Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended sleep study (95811). 
 
You asked the Plan to pre-approve an attended sleep study. The Plan denied your request. The Plan says you do 
not meet the criteria for the service requested.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an attended sleep study. Our reviewer 
says that an attended split-night polysomnogram with positive airway pressure (PAP) titration is not medically 
necessary. Our physician reviewer found you had a polysomnogram, presumably a home sleep test, that 
showed mild sleep apnea, with an apnea-hypopnea index of 8.8. You could be started on treatment with 
continuous positive airway pressure (CPAP), with an auto titrating device. Our reviewer found if your sleep 
disordered breathing is not adequately treated with the auto titrating device, then a formal attended PAP 
titration study could be obtained. Our physician reviewer also found that a repeat diagnostic portion of the 
study 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 an attended sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an attended sleep study (95811).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76937 and 36000 billed for date of service 
November 22, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are correct. The Plan denied your 
request. The Plan says procedure code 36000 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 looked at the file and the rules. We find that procedure code 36000 has a status indicator of B on the 
Physician Fee Schedule. This means that procedure code 36000 is not separately payable. 
 
The code definition of code 76937 is ultrasound guidance for vascular access requiring ultrasound evaluation of 
potential access sites, documentation of selected vessel patency, concurrent real time ultrasound visualization 
of vascular needle entry, with permanent recording and reporting (List separately in addition to code for 
primary procedure). We find that code 76937 was not billed with a valid primary procedure code. 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 codes 76937 and 36000 billed for date of service 
November 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat home sleep study (95800). 
 
You asked the Plan to pre-approve a repeat home sleep study. You say that you would like the enrollee to have 
another home sleep study in support of a new CPAP equipment. The Plan denied your request. The Plan says 
the enrollee's OSA diagnosis was made almost 9 years before and their OSA symptoms have reappeared. The 
Plan also says therefore, the enrollee does not need a home sleep test (HST) for diagnosis. 
 The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography studies may be indicated 
for the conditions listed in the Medicare rules section of this letter 
 
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 repeat home sleep study. Our 
reviewer says that a repeat home sleep test is not medically necessary. Our physician reviewer found the 
enrollee has severe obstructive sleep apnea (OSA), diagnosed on a split-night attended polysomnogram in July 
2014. The enrollee was started on continuous positive airway pressure (CPAP) which they tolerated well. Our 
reviewer found that recently the device was recalled by the manufacturer and the enrollee discarded it. The 
enrollee is looking for a new CPAP device. Our physician reviewer found there is no indication in the records 
that the enrollee was having any recurrence of OSA symptoms or difficulty using CPAP prior to the recall of 
the device. Because the enrollee already has a diagnosis of OSA, and there is no documentation of major 
changes in body weight or health status, a repeat diagnostic sleep study is not medically necessary. Our 
reviewer found that a replacement device can be initiated at the patient's previous settings. Our physician 
reviewer also found that a repeat split-night study with positive airway pressure titration would be necessary 
only if the new CPAP device does not adequately treat the sleep disordered breathing. 
 
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 repeat home sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat home sleep study (95800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the lower 
spinal canal. 
 
You asked the Plan to pre-approve the MRI of the spine. You say that the services are necessary to determine 
the pain management needed for the enrollee. The Plan denied your request. The Plan says the request does not 
meet the Medicare or health plan coverage criteria. 
 
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 the MRI of the spine. Our reviewer says 
that the MRI is not medically necessary. Our physician reviewer found during the encounter on April 1, 2023, 
the enrollee was neurologically intact with normal strength and reflexes. The X-rays showed multilevel 
degenerative changes. There are no records of a 6-week trial of physical therapy prior to the request for the 
MRI. Criteria is not 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 the MRI of the spine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the magnetic resonance imaging (MRI) of the lower spinal canal.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments. 
 
You asked the Plan to pre-approve these services. You say that chiropractic services are medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 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.  
 
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 
you do not meet criteria for coverage of the requested services. Our physician reviewer found that in this case, 
the record indicates that you have chronic lumbar pain with radiculopathy in the setting of foraminal stenosis. 
The record provided does not document the presence of a subluxation of the spine demonstrated by x-ray or 
physical examination. The elements of the coverage criteria are not satisfied. The requested services are not 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pessary and fitting received on October 26, 2022.  
You asked the Plan to pay for pessary and fitting. You say that you paid for this out of pocket and was 
supposed to have been refunded upon return. The Plan denied your request. The Plan says an itemized 
statement was not provided. 
 
The Plan must follow Medicare rules. The rules say that you may be reimbursed for covered services under 
certain conditions.   
 
While you have submitted a copy of a bill for the item provided, the bill submitted is not itemized. This means 
the services/items received are not supported. In addition, the amount at issue was for a refundable deposit. The 
documentation shows that you did not return this item. This amount is not payable to you as billed. Therefore, 
we decided that the Plan does not have to pay for pessary and fitting received on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutmentincludes modification and 
placement (D6056) provided on October 19, 2022.  
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not covered under the supplemental 
dental policy. 
 
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, the item provided is not among those 
covered under this benefit. Additionally, please note that we do not have jurisdiction over the amounts charged 
for services. Therefore, we decided that the Plan does not have to pay for the prefabricated abutmentincludes 
modification and placement (D6056) provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service July 5, 2022. 
 You asked the Plan to pay for procedure code 99291. You say that there are no additional claims on this date. 
The Plan denied your request. The Plan says payment for code 99291 is bundled into payment for code 92950. 
 
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, we have confirmed that code 99291 is a column II code to column I code 92950. The code at issue 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99291 billed for date of service July 5, 2022.
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 the enrollee currently meets LTACH 
requirements. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
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 that the acute hospital can provide for all the enrollees present inpatient care needs, 
and the enrollee is receiving an appropriate level of care in the present setting.  
 The provided records do not explain what care services will be provided in the LTACH that are not available in 
the present hospital setting.  
The enrollee is presently receiving appropriate services in the acute care setting. Continued care in the short-
term acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an 
inpatient rehabilitation facility, a sub-acute rehabilitation facility, or a skilled nursing facility. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are currently recovering from a 
traumatic brain injury and your physicians feel that long tern acute care is imperative for continued recovery 
and your next care step of inpatient rehabilitation. The Plan denied your request. The Plan says your records do 
not show you need continued treatments and care that can only be given in a hospital setting, when you are 
ready to leave the hospital, you can safely receive this care in another setting, at an Inpatient Rehabilitation 
Facility, a Skilled Nursing Facility or at home with home health services. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial nerve stimulation (PTNS). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of PTNS is supported by the 
American Urological Association as a treatment for overactive bladder after trial and failure of conservative 
therapy and medication. The records do not show that your diagnosis has failed treatment with conservative 
therapy and medication; therefore, the PTNS is not reasonable or medically necessary at this time. 
 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 posterior tibial nerve stimulation (PTNS).  
 
Local Coverage Determination (LCD) L33396 referenced by the Plan is not valid for the state of Florida and 
was not used in the MAXIMUS determination.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecule pathology procedure (PrismRA test) 
(81479) provided November 22, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that the laboratory services that the member received 
were medically necessary and you have submitted medical documentation to support. The Plan denied your 
request. The Plan says under Medicare guidelines, the PrismRA Test requested does not meet the requirements 
for approval. 
 
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 PrismRA test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the PrismRA Test at issue 
in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. The provided 
records in this case include a letter of medical necessity, the test requisition and the test results. The records do 
not document the enrollee is a candidate for or is a clinical non-responder to tumor necrosis factor inhibitor 
therapy to meet criteria for the test. 
 
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 PrismRA test have not been met. Therefore, we decided that the Plan does 
not have to pay for the unlisted molecule pathology procedure (PrismRA test) (81479) provided November 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ZooMe AutoFlex Folding Travel Scooter (K0899). 
 
You asked the Plan to pre-approve the ZooMe AutoFlex Folding Travel Scooter. You say that you feel this 
scooter is medically necessary. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that POV/PWCs coded as K0899 will be denied as 
not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ZooMe AutoFlex Folding Travel Scooter have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the ZooMe AutoFlex Folding Travel Scooter (K0899).