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

 
We decided that the Plan does not have to pre-approve fluorouracil, leucovorin, oxaliplatin, nivolumab, 
trastuzumab-dttb, dexamethasone sodium phosphate, diphenhydramine, aprepitant and palonosetron. 
 
You asked the Plan to pre-approve the drugs. You say that you are requesting reconsideration for the denial of 
the enrollee's chemotherapy regimen for palliative care. The Plan denied your request. The Plan says the 
requested treatment 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 fluorouracil, leucovorin, oxaliplatin, 
nivolumab, trastuzumab-dttb, dexamethasone sodium phosphate, diphenhydramine, aprepitant and 
palonosetron. Our reviewer says that the requested drug combination is not medically necessary. Our physician 
reviewer found the provided records do not document advanced human epidermal growth factor receptor 2 
(HER2) overexpression positive adenocarcinoma. The requested regimen does not meet Medicare criteria for 
safe and effective and 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 the drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve fluorouracil, leucovorin, oxaliplatin, nivolumab, trastuzumab-dttb, dexamethasone sodium 
phosphate, diphenhydramine, aprepitant and palonosetron.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87502 billed for date of service October 24, 
2022. 
 You asked the Plan to pay for procedure code 87502. The Plan denied your request. The Plan says payment for 
code 87502 is bundled into payment for code 87633. 
 
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 87502 
is a column II code to column I code 87633. 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 87502 billed for date of 
service October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
February 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the billed codes. 
The Plan denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the infusion therapy, billed with codes 96365 and 96366 were billed in an outpatient setting. There 
is a more accurate code to describe the services provided. Outpatient intravenous insulin therapy is not a 
covered service. 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 96365 and 
96366 billed for date of service February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive hereditary pharmacogenomics testing and 
the hereditary genetic cardiac test panel provided on September 28, 2022.  
 
You asked the Plan to pay for the comprehensive hereditary pharmacogenomics testing and the hereditary 
genetic cardiac test panel. You say that this testing was medically necessary. The Plan denied your request. The 
Plan says there is no documentation of the drugs being considered for use, and no documentation to how the 
results will 
impact treatment.  
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when medically necessary and 
the criteria in the rules section of the letter are met. 
 
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 comprehensive hereditary 
pharmacogenomics testing and the hereditary genetic cardiac test panel. Our reviewer says that the service is 
not medically necessary. Our physician reviewer found that the test is described as a genetic based 
cardiovascular risk factor screening test in which multiple genes are assessed using genomic DNA extracted 
from patient sampling. It assesses the presence of pathogenic or likely pathogenic variants in genes known to 
be associated with increased cardiac risk. It is not a diagnostic test. There is no evidence to support its role in 
this patient clinical management. In summary, the requested testing is not considered reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the comprehensive hereditary pharmacogenomics testing and the hereditary 
genetic cardiac test panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
comprehensive hereditary pharmacogenomics testing and the hereditary genetic cardiac test panel provided on 
September 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive extracranial arterial study. 
 
You asked the Plan to pre-approve a non-invasive extracranial arterial study. You say that the requested  
non-invasive extracranial arterial study is medically necessary. The Plan denied your request. The Plan says the 
requested non-invasive extracranial arterial study does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that non-invasive extracranial arterial study is covered 
when the criteria listed in the Medicare rules section of this decision are met.  
 
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 non-invasive extracranial arterial 
study. Our reviewer says that a non-invasive extracranial arterial study is not considered medically necessary in 
this case. Our physician reviewer found the enrollees physical exam revealing normal carotid pulses and no 
bruits. The documentation does not support the rationale for this imaging study. Guidelines do not support a 
need for carotid duplex scan extracranial bilateral study. As a result, at this time cardiac doppler imaging would 
not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 non-invasive extracranial arterial study have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a non-invasive extracranial arterial study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental 
pneumatic appliance for use with pneumatic compressor (E0667). 
 You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance. You say that 
the medical records meet the coverage criteria listed in the National Coverage Determination (NCD) 280.6. The 
Plan denied your request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0650 or E0651 is covered for both 
primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the three 
requirements listed in the Medicare rules section of this letter are met. 
 
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 pneumatic compressor and segmental 
pneumatic appliance. Our reviewer says that the enrollee does not meet the LCD coverage criteria for a 
pneumatic compressor (E0651) and segmental pneumatic appliance for use with pneumatic compressor 
(E0667). Our physician reviewer found the enrollee has a diagnosis of lymphedema. They were evaluated by 
their provider on June 19, 2023, and the medical records from that visit say that they also have chronic venous 
stasis ulcers. Our reviewer found that the enrollee has tried using conservative therapy for four weeks but still 
has symptoms. Our physician reviewer also found that the records received from the provider did not include 
any objective findings of swelling during the course of treatment, such as measurements, to document the 
response to conservative therapy. 
 
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 pneumatic compressor and segmental pneumatic appliance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and 
segmental pneumatic appliance for use with pneumatic compressor (E0667).
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 meets Medicare criteria and will benefit 
from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on March 07, 2023. 
 
You asked the Plan to waive the copayment for office visit. You say that you say that this is a follow-up visit 
from the surgery. 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on March 07, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on February 24, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes". 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided do not 
show that 30-74 minutes of critical care services were provided on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care services (99291) provided on February 24, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xofigo. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the enrollee is 
enrolled in a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the medication as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Xofigo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 enrollee is being treated for 
vertebrogenic low back pain. There are multiple documented plausible pathologic sources of significant pain 
generation. The records are lacking regarding reasonably detailed and/or evidenced findings supportive of the 
spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
The documentation does not support the Intracept procedure as medically necessary and/or reasonable 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 an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve intravenous sedation (D9239, D9243). 
 
You asked the Plan to pre-approve intravenous sedation. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says that the criteria for approval have not 
been met. 
 
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. The Plan covers intravenous 
sedation when the services are medically necessary and reasonable. 
 
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 intravenous sedation. Our reviewer says 
that the requested services are medically necessary. Our physician reviewer found that you have a heart 
condition and have had an open-heart surgery in the past. You need surgical extractions of tooth #25, 26, and 
27. With extractions, sedation is sometimes necessary. The type of sedation administered to a patient is based 
off their discussion with their dental provider as what would be optimal with consideration of their medical 
history. The oral surgeon is requesting the sedation for your safety during the extraction procedures, and this 
reason warrants medically necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of intravenous sedation have been met. Therefore, we decided that the Plan has to 
pre-approve intravenous sedation (D9239, D9243).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual wheelchair supplies and accessories (E0971, E0978, 
E2601 E2611, K0015, K0195) billed for date of service November 8, 2022. 
 
You asked the Plan to pay for manual wheelchair supplies and accessories. You say that you have reported the 
items at issue correctly. 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 proof of delivery for the supplies provided in this case. The case record 
contains a delivery ticket for the date of service at issue; however, the supplies at issue in this case are not 
listed on the ticket. 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 manual 
wheelchair supplies and accessories (E0971, E0978, E2601 E2611, K0015, K0195) billed for date of service 
November 8, 2022.
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) 
following cardiac surgery. The enrollee is not intubated/ventilated. There is no evidence that the enrollee 
requires services that are not currently available. Our reviewer found that as LTACHs and ACHs are licensed 
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee 
can remain at the current ACH until such time no acute services are required. Our physician reviewer also 
found that the enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the chest. 
 
You asked the Plan to pre-approve the CT of the chest. You say that the services are medically necessary. The 
Plan denied your request. The Plan says they do not have the medical records to determine if the services are 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the CT of the chest. have been met. The Plan requested medical records but did not receive any, and without medical records we cannot determine 
whether you meet the criteria for a computed tomography (CT) of the chest. Therefore, we decided that the 
Plan does not have to pre-approve computed tomography (CT) of the chest.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on February 7, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the office setting POS code. 
The records do not support that the services were provided in an office setting. Therefore, we decided that the 
Plan does not have to pay for the imaging services provided on February 7, 2023.