Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that your doctors 
at Urgent Care prescribed mental health counseling with considerable urgency. You say that you built a list of 
all qualified counselors and narrowed the list down to a few providers that specialize in trauma counseling and 
have eye movement desensitization and reprocessing (EMDR) therapy qualifications. You say that after several 
months of looking for a counselor, you found one that you trust, and you have already had one appointment 
with this provider. The Plan denied your request. The Plan says the requested services are neither emergent nor 
urgent to seek out-of-network care. The Plan says they have several in-network providers who specialize in 
post-traumatic stress disorder (PTSD), provide EMDR therapy, are accepting new patients, and can treat you in 
person.  
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 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a HGNS. 
 
You asked the Plan to pre-approve the HGNS. You say that you cannot sleep with a sleep apnea machine. Your 
last sleep study showed you stopped breathing when you sleep 20 to 30 times per night. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for an item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiarys medical documentation and confirm that Medicare coverage criteria have 
been met. Medicare rules also say that hypoglossal nerve neurostimulation is only covered when medically 
necessary for the treatment of moderate to severe obstructive sleep apnea when a polysomnography has been 
performed within 24 months of the first consultation for the HGNS implant.  
 
We looked at the file and Medicare rules. The case file did not include any documentation demonstrating that 
the enrollee received polysomnography services within 24 months of the first consultation for the HGNS 
implant. Based on this information, we decided that Medicare rules for coverage of the HGNS have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a HGNS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a BiPAP device with average volume-assured pressure support (AVAPS). 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has not tried and failed BiPAP therapy, and there is no documented failure of a BiPAP or evidence of 
worsening respiratory failure. The enrollee is also complaint and has been treated with a CPAP without failure. 
The best practice approach would be BiPAP therapy if the enrollee is not treated accordingly with a CPAP. 
Furthermore, there is no indication for a home ventilator. 
 
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 home ventilator system have been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital alcohol detoxification. 
 
You asked the Plan to pre-approve inpatient hospital care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee's symptoms do not warrant an inpatient level 
of care. 
 
The Plan follows Medicare rules. Medicare rules state that inpatient hospital stays for treatment of alcoholism 
may be covered in certain cases. 
 
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 inpatient hospital care. Our reviewer 
says that the enrollee does not meet criteria for inpatient hospital care. Our physician reviewer found it is not expected that the enrollee will improve in a reasonable period of time as the enrollee is not showing danger to 
self or others, hallucinations, or aggressive behaviors and is not showing any symptoms of withdrawal. The 
enrollee could be treated in a less restrictive 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 inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient hospital alcohol detoxification.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard testing (81528).

You asked the Plan to pre-approve Cologuard testing. You say that the testing is medically necessary. The Plan
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been
met.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Cologuard testing.
Our Medical Director states that the enrollee was being screened for colon cancer. The Progress Notes dated
February 22, 2023, an annual wellness exam, documents that the enrollee was not wanting colonoscopy at that
time. The family history documents father deceased, diagnosed with heart disease, and mother deceased. Fecal
occult blood testing was recommended yearly. Notes included "f/u stool guiac." The surgical history was
notable for "intestinal obstruction." The available clinical documentation in the case file does not support that
the enrollee in this case met the coverage criteria established by the NCD. Our Medical Director found that the
enrollee's condition does not meet criteria for coverage of Cologuard testing.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Cologuard testing have not been met. Therefore, we decided that the Plan does
not have to pre-approve Cologuard testing (81528).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic images 
(D0230 x 10) provided on August 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the intraoral x-rays 
provided has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral x-rays provided was exhausted on date of service August 31, 2023.  
  
 
Specifically, the Plans contract states that one intraoral x-ray is covered per calendar year. On this day, you 
received 11 intraoral x-rays, of which one was paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the intraoral-
periapical additional radiographic images (D0230 x 10) provided on August 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that you are appealing based on the records submitted. The 
Plan denied your request. The Plan says for the enrollee's Medicare part B benefit to cover the requested drug, 
it must be furnished by a physician, an infusion center, or the hospital outpatient department. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Stelara.  
 
Benefits for Stelara may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment and acupuncture 
without electrical stimulation provided on September 13, 2023, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the chiropractic manipulative treatment and acupuncture without electrical 
stimulation. You say that you are a participating provider with traditional Medicare and in the past all Medicare 
type or Medicare Advantage plans have paid whether you had a contract with that Plan or not. The Plan denied 
your request. The Plan says the chiropractic manipulative treatment and acupuncture without electrical 
stimulation is available in network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment and 
acupuncture without electrical stimulation provided on September 13, 2023, by an out-of-network (OON) 
provider.
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 the enrollee has daily wound care needs 
requiring LTACH services. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval of the requested LTACH 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 reviewer 
found the enrollee does not require services at the LTACH that are not already available at the current acute 
care hospital. The requested LTACH services are not appropriate for the diagnosis and condition of the 
enrollee. Medically necessary care can be furnished safely and effectively at the current 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve luspatercept.  
 
You asked the Plan to pre-approve luspatercept. You say that there is sufficient data on the safe and effective 
use of luspatercept for chronic myelomonocytic leukemia when other therapies have been unsuccessful. The 
Plan denied your request. The Plan says that the requested drug is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve luspatercept. Our reviewer says that the 
requested drug is medically necessary. Our physician reviewer found that luspatercept-aamt is approved for the 
treatment of anemia without previous erythropoiesis stimulating agent use (ESA-naive) in adult patients with 
very low- to intermediate-risk myelodysplastic syndromes (MDS) who may require regular red blood cell 
(RBC) transfusions. The PACE-MDS phase 2 trial shows support for this use. The article that supports its use 
can be found at https://ascopubs.org/doi/full/10.1200/JCO.21.02476. The quoted trial has demonstrated it to be 
safe and effective. It is otherwise reasonable and necessary for the 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 luspatercept have been met. Therefore, we decided that the Plan has to pre-
approve luspatercept.   
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493, 64494, 20610, and 27096 billed for 
date of service May 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that records were provided. 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. 
 
In this case, the CPT Code Manual definition of code 64493 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level. The definition of code 64494 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; second level (List separately in addition to code for primary procedure). 
 
The definition of code 20610 is arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, 
hip, knee, subacromial bursa); without ultrasound guidance. The definition of code 27096 is injection 
procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including 
arthrography when performed. 
 
We find that CPT codes 64493, 64494, 20610, and 27096 are not supported in the medical record. In this case, 
there are limited medical records that were provided. The records do not include a procedure note or operative 
report that documents the services at issue. 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 64493, 64494, 20610, and 27096 billed for date of service May 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151 x8), home health 
skilled nursing (G0299 x5), and home health aide (G0156 x9). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
and his caregiver have been educated regarding his medical conditions and medications. He does not require 
wound care, catheterization, tube feeding, or administration of intravenous or complex medications. The 
enrollee has not recently been hospitalized. The enrollee requires supervision and oversight for safety with 
mobility and daily activities, but his progress with therapy has not significantly changed and his progress has 
plateaued. This does not necessitate skilled physical therapy in the home. The enrollee is also noted to have a 
caregiver for assistance with daily activities and supervision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151 x8), home health skilled nursing (G0299 
x5), and home health aide (G0156 x9).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system 
 
  You asked the Plan to pre-approve a home ventilator system.. You say that the enrollee needs a non-invasive 
ventilation system at home to manage their advanced disease and to prevent future hospitalizations. You say 
that the enrollee is at a high risk for hospital readmission and potentially life0threatning exacerbations. The 
Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient because 
their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The enrollee has been successfully 
treated with a BiPAP and was ordered a device in AVAPS mode. However, the documentation does not contain 
sufficient detailed information in the medical records to justify the treatment selected. The enrollee can be 
treated with a BiPAP machine with AVAPS capability and failure of such a device has not been documented. 
Furthermore, ventilators fall under the frequent substantial servicing (FSS) payment category, and payment 
policy requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive 
airway pressure, regardless of the illness treated by the device. Therefore, the elements of the coverage criteria 
are not satisfied, and the requested service cannot be 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 a home ventilator system. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system
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 needs inpatient rehabilitation to get back 
the independence they had before being hospitalized. The Plan denied your request. The Plan says the 
enrollee's condition does not meet all the requirements for inpatient rehabilitation admission and services may 
be provided at 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 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.  The enrollees 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.