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

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Leqembi. Our reviewer says that 
Leqembi is not medically reasonable and necessary in this case. Our physician reviewer found that the record 
indicates that the enrollee has Alzheimers dementia. The record provided is insufficient to determine that the 
requested drug is being prescribed for a medically accepted indication as defined by Medicare rules. The Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The record does not indicate that the requested drug is being used in the context of 
a Medicare approved clinical trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99204) provided on January 5, 2023. 
 
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 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
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 the services. Our reviewer says that the use of code 99204 is not supported by the records provided. Our reviewer found that the procedure report does not support a 
moderate level of complexity. The documentation supports a low level of medial decision making. The 
procedure report does not include documentation of time. 
 
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 the services (99204) provided on January 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care billed for dates of service August 
12, 2022, to August 26, 2022. 
 
You asked the Plan to pay for the billed services. 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 CT code. 
 
The file shows that lab and diagnostic testing was provided on August 8, 2022. These services are outside of 
the dates of service at issue. Based on this information, we decided that the Medicare rules for coverage have 
not been met.  
 We find that CPT code 51702 was billed for date of service August 13, 2022. CPT codes 97167, 97530, and 
97163 were billed for date of service August 15, 2022. CPT code 97530 was billed for dates of service August 
16, 18, 22, and 24, 2022. CPT code 51798 was billed for dates of service August 13 and 19, 2022.  
 
We find that the CPT codes at issue are not supported in the medical record for the dates billed. 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 the inpatient hospital care billed for dates of service August 
12, 2022, to August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided January 1, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of coverage for 
the Cxbladder Detect test. The Plan denied your request. The Plan says Cxbladder tests are considered 
experimental and investigational. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The peer reviewed medical literature, has not demonstrated the 
analytical validity and clinical utility outcomes of Cxbladder Detect. Based on this information, we decided 
that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the 
Plan does not have to pay for the Cxbladder Detect test (0012M) provided January 1, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88185 billed for date of service April 5, 2021. 
 
You asked the Plan to pay for procedure code 88185. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. The Plan has not provided a clear and specific rationale for denying the services 
at issue. It is the Plan's responsibility to support its denial with evidence. In this case, the Plan has not 
supported its denial, so we must find in your favor. Therefore, we decided that the Plan has to pay for 
procedure code 88185 billed for date of service April 5, 2021.  
 
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 pre-approve rhytidectomy, cheek, chin, and neck.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is considered cosmetic.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that in this case, the record indicates that the enrollee has a history of gender dysphoria and has undergone facial feminization procedures previously. The record provided documents that the requested procedure is to improve appearance and not to repair a malformed body member or functional impairment. The elements of the coverage criteria are not satisfied.

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve rhytidectomy, cheek, chin, and neck.
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 you need more skilled nursing to increase mobility 
with a wheelchair. The Plan denied your request. The Plan says the SNF services you are requesting do not 
meet the requirements for approval. 
 
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 require skilled nursing or skilled therapy services that require the 
specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. You do not require 
skilled services on a daily basis. You do not require skilled services on an inpatient basis in a 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 20, 2022, to 
October 18, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says you have attempted to submit the NOA numerous times, but each 
time the NOA was invalid because the bill type was incorrect.  To date, the Plan has not received a valid NOA. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, a valid NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from September 
20, 2022, to October 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging, single-photon emission 
computerized tomography (SPECT) scan (78452). 
 
You asked the Plan to pre-approve a myocardial perfusion imaging, SPECT scan. You say that the enrollee 
needs cardiac clearance to have cataract surgery. You also say that you recommend the stress test to complete 
cardiac clearance. The Plan denied your request. The Plan says the records do not show that the enrollee has a 
high risk for coronary artery disease, exercise treadmill testing alone would be unreliable or inconclusive and 
the surgery planned is vascular or intermediate risk non-cardiac surgery. The Plan also says that this request is 
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 a myocardial perfusion imaging, 
SPECT scan. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no documentation that the electrocardiogram 
(ECG) shows an uninterpretable pattern or that the enrollee is unable to exercise. There is no evidence provided 
that would support the need for radionuclide stress testing at this time. Our reviewer also found that there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing 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 myocardial perfusion imaging, SPECT scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a myocardial perfusion imaging, single-photon emission 
computerized tomography (SPECT) scan (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection (E2311), harness (E2313), and expandable 
controller (E2377). You say that when three or more power seating functions/actuators/motors are provided, 
one unit of E2311, one unit of E2377, and one unit of E2313 are allowed. The Plan denied your request. The 
Plan says although there are three requested power options (tilt, recline and elevating leg rests), there is not a 
medical need to control these power options through the joystick. 
 
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 electronic connection (E2311), 
harness (E2313), and expandable controller (E2377). 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 
arthritis, a previous stroke from 2017. The enrollee has 4 out of 5 strength in their upper extremity. Our 
reviewer also found that the enrollee has adequate upper body strength to manage standard power drives. 
 
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 electronic connection (E2311), harness (E2313), and expandable controller 
(E2377). have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), harness (E2313), and expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and electrocardiogram (EKG) provided on 
December 8, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the providers office advised they accept 
your plan. You say that that is why you go there. You also say that when you call the office you are advised 
you do not owe anything. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. 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 and electrocardiogram (EKG) provided on 
December 8, 2022, by an out-of-network (OON) provider.
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 these services are a medical need for the enrollee to 
function and return to independent living.  The Plan denied your request. The Plan says these services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (80307, G0482) provided on January 6, 
2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary. The Plan denied your 
request. The Plan says there is insufficient documentation to support these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 drug testing have been met. 
Specifically, no laboratory results were provided to support that these services were performed and reported 
with accurate codes. Therefore, we decided that the Plan does not have to pay for drug testing services (80307, 
G0482) provided on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is a 
necessity for your care. The Plan denied your request. The Plan says that the requested item is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that a portable oxygen concentrator is medically reasonable and necessary in this case. Our 
physician reviewer found that you have end-stage lung cancer on palliative chemotherapy regimen and chronic 
obstructive pulmonary disease (COPD). You are on chronic oxygen and cannot be mobile with large tank of oxygen. Therefore, a portable oxygen tank/therapy is reasonable and medically necessary for your continued 
care and therapy and to perform your activities of daily living (ADLs). 
 
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 portable oxygen concentrator have been met.  Therefore, we decided that the 
Plan has to pre-approve a portable oxygen concentrator (E1392).  
 
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 pre-approve an oxygen concentrator and portable oxygen. 
 
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. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 criteria for coverage are not met. Our physician reviewer found there is no documentation of oxygen 
saturation levels below 88 percent or an arterial blood gas (ABG) study or ambulatory study to confirm that 
you need home oxygen therapy. The criteria for coverage are not met and the home oxygen concentrator and 
portable concentrator are 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 these services have not been met.  Therefore, we decided that the Plan does not 
have to pre-approve an oxygen concentrator and portable oxygen.