Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the provider is not in the member's network. The Plan 
states the member's plan covers providers outside of their network only when their medical needs cannot be 
met in the member's network. The Plan states the provider did not provide records that show this is the case. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy administrative services provided 
on March 31, 2020, billed with code S9338. 
 
You asked the Plan to pay for the home infusion administrative services. You say that these services should be 
covered. The Plan denied your request. The Plan says this is not a valid code for Medicare. 
 
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 CPT code S9338 has a status indicator of "I" on the Physician Fee Schedule, meaning that it is 
invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage 
of the home infusion administrative services have not been met. Therefore, we decided that the Plan does not 
have to pay for the home infusion therapy administrative services provided on March 31, 2020, billed with 
code S9338.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged evaluation and management service (99358) 
provided on June 11, 2020. 
 
You asked the Plan to pay for the prolonged evaluation and management service. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
provided does not support one hour of complex care management or complex decision making. 
 
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 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
 
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 prolonged evaluation and management 
service. Our reviewer says that the billing of CPT code 99358 is not supported. Our physician reviewer found 
the brief note does not show that one hour of prolonged evaluation and management services were provided on 
the billed date of service. 
 
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 prolonged evaluation and management service have not been met. 
Therefore, we decided that the Plan does not have to pay for the prolonged evaluation and management service 
(99358) provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve a complete maxillary denture and a complete mandibular denture. You say 
that the set you have is too big and makes your mouth hurt. The Plan denied your request. The Plan says you 
had claims paid for dentures on June 22, 2016 and therefore are not eligible yet. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a complete 
maxillary denture and a complete mandibular denture with a frequency limit of once per 60 months.  
 
We looked at the file and Medicare rules. The record shows you had this service less than 60 months ago. 
Based on this information, we decided that the Plan's rules for coverage of a complete maxillary denture and a 
complete mandibular denture have not been met. Therefore, we decided that the Plan does not have to pre-
approve a complete maxillary denture and a complete mandibular denture.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve electrical stimulation device used for cancer treatment, includes all 
accessories, any type (CPT Code E0766) to be provided by an out-of-network provider. 
 
 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the Medicare rules have not been met for E0766. 
 
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 services. Our physician reviewer 
found the above Medicare criteria are met. The service is reasonable and 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 services have been met. Therefore, we decided that the Plan has to pre-
approve electrical stimulation device used for cancer treatment, includes all accessories, any type (CPT Code 
E0766) to be provided by an out-of-network provider.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown. 
 
You asked the Plan to pre-approve the crown. You say that you need the crown and cannot afford to pay for it. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. The Plan contract clearly states that crowns are excluded from coverage under 
your plan. Therefore, we decided that the Plan does not have to pre-approve a dental crown.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq with heparin sodium injection. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has muscle-invasive 
transitional cell carcinoma of the bladder. She was on pembrolizumab for a T2N0 bladder cancer and 
progressed with liver metastases. Switching from one PD-L1 inhibitor after progression on a prior PD-L1 
inhibitor is not indicated as unlikely to be effective. The use of Tecentriq for this enrollee is unlikely to be 
effective and use in to 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tecentriq with heparin sodium injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the behavioral health evaluation services coded as 
99213, 90791, 90834 and 90837 to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the behavioral health services. You say that this provider is a female 
therapist that you feel more comfortable discussing things with. You were originally approved to see both 
providers a year ago and feels it should not be this hard. The Plan denied your request. The Plan says enrollee's 
must receive their medical services from an in-network provider. If an enrollee requires medical care that 
Medicare requires the plan to cover and there are no in-network providers who can provide the care, then the 
enrollee can receive the care from an out-of-network provider. The plan has confirmed that in-network 
providers are available. 
 
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 
the behavioral health evaluation services coded as 99213, 90791, 90834 and 90837 to be provided by an out of 
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the off-label use of this drug for this condition is not medically accepted. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has a 
diagnosis of anemia, unspecified. The documentation does not support a diagnosis of renal disease, 
chemotherapy, or HIV. The documentation notes a diagnosis of macrocyctic anemia from unknown etiology.  
The enrollee's diagnosis is not supported by the compendia. Medical necessity cannot be determined. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit for the enrollee.
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 medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can 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 above. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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: 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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (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. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care (LTC) 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electronic analysis of implanted neurostimulator pulse 
generator/transmitter (95972) provided on October 22, 2019. 
 
You asked the Plan to pay for the electronic analysis. You say that you would like reconsideration based on the 
record submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 95972 is electronic analysis of implanted neurostimulator 
pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off 
cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, 
detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health 
care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse 
generator/transmitter programming by physician or other qualified health care professional.  
 
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 electronic analysis. Our reviewer says that CPT code 
95972 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative 
report does not include enough documentation to confirm that CPT 95972 has been performed. 
 
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 electronic analysis have not been met. Therefore, we decided that the Plan 
 
 
does not have to pay for the electronic analysis of implanted neurostimulator pulse generator/transmitter 
(95972) provided on October 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox for the enrollee. 
 
You asked the Plan to pre-approve Botox. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the continued use of Botox injections is not supported if the enrollee 
has not received any benefit. 
 
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 Botox. Our reviewer says that Botox is 
not medically reasonable and necessary for the enrollee in this case. The enrollee has a diagnosis of left hand 
dystonia, with tremor, posturing, and myoclonus. The neurologist documents that the enrollee "has had 3x 
botox, but feels not much has improved." The documentation does not specify the serotype used, or when the 
previous Botox injections were administered. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 15 and an occlusal 
guard (D9944). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says core build 
up is not listed as a covered service. The Plan says occlusal guard is not listed as covered either.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item and service are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for tooth # 15 and an occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower partial dentures (D5214). 
 
You asked the Plan to pre-approve the dentures. You say that you only have 4 front teeth and no molars. You 
are not able to chew without molars. The Plan denied your request. The Plan says this request exceeds the 
benefit frequency limitation of once every 60 months (5 years). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract 
specifically says that replacement of lost or broken dentures less than 5 years of age is not a covered benefit. 
The records show that you received this service on June 15, 2019.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
lower partial dentures (D5214).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says custodial care is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, 
there is no documentation that you require skilled nursing or skilled therapy services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse or qualified therapist is not required to safely and 
effectively provide medically necessary and reasonable treatment. You do not require the services on an 
inpatient basis, in a skilled nursing facility setting. Services in a long-term care facility on a part time basis 
appear appropriate in this case. 
 
 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).