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 services are medically necessary as you are a fall 
risk and are unable to take care of yourself. The Plan denied your request. The Plan says you do not meet the 
criteria for admission to 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 you are medically stable. Your rehab needs do not require an acute hospital inpatient 
rehab stay with an interdisciplinary approach to rehabilitative care. Your rehab needs can be safely provided in 
an alternate and low intensity setting such as in 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac ultrasound provided on May 08, 
2023. 
 
You asked the Plan to waive the copayment for the cardiac ultrasound. You say that you had to go to a different 
location, resulting in an additional charge. 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 $45 
copayment for in-network outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $45 copayment for the cardiac ultrasound. This item/service falls within the in-
network outpatient diagnostic tests, including ultrasounds 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. The record shows this claim was approved and you 
are responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the cardiac ultrasound provided on May 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for each mental health care office visit provided on February 07, 
2023, to March 01, 2023. 
 
You asked the Plan to pay for each mental health care office visit. You say that you would like this provider to 
be paid by the Plan. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for each mental health care 
office visit provided on February 07, 2023, to March 01, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says you do not require daily skilled services on an inpatient basis at the SNF 
level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ZOOME3 scooter (K0899). 
 
You asked the Plan to pre-approve a ZOOME3 scooter. You say that you need a foldable scooter as you have a 
small car and need a scooter that can be folded to put in the trunk of the car or back seat. You also say that 
when you go to the grocery store you are unable to do your shopping after going down one aisle and most times 
the stores do not have any scooters. The Plan denied your request. The Plan says you are requesting a non-
covered recreational scooter for use outside the home. The Plan also says this request is not reasonable or 
necessary at this time. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a ZOOME3 scooter (K0899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 10, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 25, 2022, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service was not authorized. 
 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 Plan contract also says that out-of-network 
physician/practitioner services are not covered. 
 
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 office visit provided on April 25, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has symptomatic hemoptysis with shortness of breath. The most recent American 
Society of Radiation Oncology (ASTRO) model SBRT coverage policy, reflecting national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically necessary when the patients 
performance status justifies aggressive treatment, and for those whose tumor burden can be completely targeted 
with acceptable risks (which does not apply in the setting of a lung cancer  growing in setting N2 disease when 
the intent is to treat only the lung cancer). In no clinical situation has SBRT been shown to be of benefit in the 
setting of Stage III disease. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 12, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee has been on treatment for some time 
now and is unable to tolerate their chemotherapy. You also say that you are requesting compassionate care for 
this elder patient so they can feel better. The Plan denied your request. The Plan says the use of this 
drug/regimen is not reasonable and 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 Keytruda. Our reviewer says that 
Keytruda is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Keytruda (J9271) is FDA-approved as a monotherapy for the enrollees diagnosis. The use is 
not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services (CMS) approved medical journal. Our reviewer also found that the use is not 
listed as not indicated, not supported or not recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 22612, 63047, 63048, 20930 and 20936 billed for date 
of service August 23, 2022. 
 
You asked the Plan to pay for procedure codes 22612, 63047, 63048, 20930 and 20936. You say that these 
services were necessary and are supported in the medical records. The Plan denied your request. The Plan says 
that this service is incidental to another service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not provided or clarified 
any information regarding what services are supposedly incidental to what other services. The Plan has not 
substantiated their denial in this case. Therefore, we decided that the Plan has to pay for procedure codes 
22612, 63047, 63048, 20930 and 20936 billed for date of service August 23, 2022.  
 
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 FoundationOne CDx testing (0037U) provided on 
January 11, 2023. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that this testing is medically necessary. 
The Plan denied your request. The Plan says this testing is not covered because the record does not show that 
the enrollee is seeking further cancer treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has 
decided to seek further cancer treatment. 
 
We looked at the file and Medicare rules. In this case the record does not show that the enrollee has decided to 
seek further treatment. Based on this information, we decided that Medicare rules for coverage of the 
FoundationOne CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the FoundationOne CDx testing (0037U) provided on January 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) using the 
ImpediMed L-Dex testing device (93702). 
 
You asked the Plan to pre-approve a BIS using the ImpediMed L-Dex testing device. You say that based on 
what you believe to be proven medical necessity, you are asking for authorization of this procedure for the 
enrollee. The Plan denied your request. The Plan says this request is not medically necessary because there is 
little evidence in the medical literature to suggest that this is an appropriate test to evaluate for lymphedema. 
The Plan also says it is not an accepted standard of medical practice for the diagnosis of lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a BIS using the ImpediMed L-Dex 
testing device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee does not have lymphedema, nor have they 
been treated for it according to the provided documentation. Our reviewer also found that the L-Dex testing has 
not been shown to improve overall outcomes better than the standard of care screening methods in current 
literature to help support its use in cases like this enrollee's. 
 
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 BIS using the ImpediMed L-Dex testing device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) using the 
ImpediMed L-Dex testing device (93702).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Entyvio. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that the 
enrollee does not meet the coverage criteria for Entyvio. Our physician reviewer found the enrollee has not 
tried and failed the required drugs. Our reviewer also found that there is no documentation provided indicating 
that the Plans required drugs would likely be less effective and/or likely have adverse effects 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23430 rendered on December 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 23430-AS-59-RT (1 units) remains not supported, 
as the records do not support this service as distinct or independent from other services performed. 
 
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 23430 is "Tenodesis of long tendon of biceps."  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure details cite the long 
head of the biceps tendon was identified and biceps tenodesis was performed to the upper border of the 
pectoralis major tendon with two #2 FiberWire sutures in figure-of-eight fashion. Then the superior aspect of 
the biceps tendon was followed toward the glenoid. However, the tenodesis was performed in conjunction with 
the overall reverse total shoulder arthroplasty. The procedure was not being performed specifically for a bicep 
tenodesis; however, the tenodesis was performed to allow for the reverse total shoulder arthroplasty. Therefore, 
the records do not support that CPT 23430 was distinct and independent from CPT 23472. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 23430 rendered on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit 99213-24 provided on July 26, 2022. 
 
You asked the Plan to pay for 99213-24. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this visit is part of the global surgery package and was not billed with a 
modifier for separate payment. 
 
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 99213 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is 
spent on the date of the encounter. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 99213-24. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the record describes a follow-up from a Mohs procedure. In this case 
there is a global period which would include the follow-up. Therefore, this procedure with modifier cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99213-24 have not been met. Therefore, we decided that the Plan does not have 
to pay for office visit 99213-24 provided on July 26, 2022.