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

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve the additional transportation. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says you are requesting additional trips 
beyond the 24 one-way trips that are allowed by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that upon your 24th on-way trip, you will have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a paraffin bath (E0235). 
 
You asked the Plan to pre-approve a paraffin bath. You say that the enrollee needs this due to his arthritis. The 
Plan denied your request. The Plan says the records do not show the enrollee has tried paraffin therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that paraffin bath units are covered when the patient 
has undergone a successful trial period of paraffin therapy ordered by a physician and the patients condition is 
expected to be relieved by long term use of this modality. 
 
We looked at the file and Medicare rules. The submitted documentation does not show that the enrollee has 
undergone a successful trial period of paraffin therapy. Based on this information, we decided that Medicare 
rules for coverage of a paraffin bath have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a paraffin bath (E0235).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional transforaminal epidural injections. 
 
You asked the Plan to pre-approve four transforaminal epidural injections. You say that the enrollee needs four 
injections for therapeutic relief. The Plan denied your request. The Plan says no more than two epidural 
injections can be performed at a single session. 
 
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 frequency for injections is no more than two injections at a 
single setting and no more than 3 in a 6-month period of time. Based on this information, we decided that 
Medicare rules for coverage of two additional transforaminal epidural injections have not been met. Therefore, 
we decided that the Plan does not have to pre-approve two additional transforaminal epidural injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional hyperbaric oxygen therapy (HBOT) 
sessions. 
 
You asked the Plan to pre-approve HBOT. You say that the enrollee needs hyperbaric oxygen therapy and 
treatment is most beneficial if uninterrupted. The Plan denied your request. The Plan says the denial of 
authorization for hyperbaric oxygen therapy is correct, because the Plan has already approved 15 additional 
visits which should be completed before further therapy is take into consideration. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy (HBOT) is only covered 
under certain clinical conditions. 
 
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 HBOT. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested 10 additional HBOT sessions. Our physician 
reviewer found these additional HBOT treatments beyond the 15 sessions the Plan has already approved are not 
medically reasonable or necessary for the enrollee. Specifically, there is no longer exposed bone. The enrollee 
has been compliant and there are no pictures or comparative measurements submitted for objective evidence of 
progress as requested by the Plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve 10 additional hyperbaric oxygen therapy (HBOT) sessions.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on March 18, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this claim is a duplicate to a previously processed 
claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We find that CPT code 71045 is not supported in the record. Specifically, the record indicates that this is a 
duplicate claim or another that was previously processed and paid. The documentation submitted does not 
show that this service was rendered multiple times of the billed date of service. Based on this information, we 
decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the 
Plan does not have to pay for the chest x-ray (71045) provided on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a MyoPro Motion G Limb orthosis (L8702). 
 
You asked the Plan to preapprove the orthosis. You say that you require this orthotic for arm weakness. The 
Plan denied your request. The Plan says there is insufficient evidence of its effectiveness for this enrollee's 
clinical presentation. 
 
The Plan must follow Medicare rules. Medicare rules say that services that are not medicall necessary are not 
covered. The rules also say that experimental and investigational are not covered. The MyoPro Motion G 
orthosis is considered to be experimental and investigational. Therefore, we decided that the Plan does not have 
to preapprove a MyoPro Motion G Limb orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network 
(OON) provider on February 13, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213) rendered by the out of network (OON) provider on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a custom ankle-foot orthosis with lacer (L1940, L2330). 
 
You asked the Plan to preapprove the orthoses. You say that the orthosis is necessary to help with pain and the 
member's condition. The Plan denied your request. The Plan says there are no objective measurements of the 
feet and no documentation to show that the member trialed and is unable to benefit from a prefabricated ankle 
orthosis. 
 
The Plan must follow Medicare rules. Medicare rules say to be covered for a custom orthosis; the beneficiary 
could not be fitted with a prefabricated. There is no documentation to show that the member trialed and is 
unable to benefit from a prefabricated ankle orthosis. Therefore, we decided that the Plan does not have to 
preapprove a custom ankle-foot orthosis with lacer (L1940, L2330).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to an oral bisphosphonate and zoledronic acid. 
 
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 Prolia (J0897). Our reviewer says that 
this drug is not reasonable and medically necessary. Our physician reviewer found the enrollee has not tried 
and failed Zoledronic acid. The prescribing physician does not document that Zoledronic acid would likely be 
less effective, and/or would likely have adverse effects for the enrollee 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 Prolia (J0897) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the core buildup (D2950) and crown (D2740) provided 
on February 10, 2020. 
 
You asked the Plan to pay more for the core buildup (D2950) and crown (D2740). You say that you understood 
you only had 50% coverage, but the allowed amount was not explained to you prior to signing up. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to 50% of 
the allowed amount for your covered dental services from an out-of-network provider. 
 
Service Billed Amount Allowed 
Amount 
50% 
Coinsurance 
Difference of 
Billed & Allowed 
Amount 
Member 
Liability 
Core Buildup $225 $100 $50 $125 $175 
Crown $940 $520 $260 $420 $680 
TOTAL:     $855 
 
  
Therefore, we decided that the Plan does not have to pay more for the core buildup (D2950) and crown 
(D2740) provided on February 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation services. 
 
You asked the Plan to pre-approve the transport trip. You say that the trip to your doctor is medically 
necessary. The Plan denied your request. The Plan says you have no benefit for routine, non-emergency 
transportation in your current plan. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the transport trip have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transportation services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Decipher biopsy testing provided on April 21, 2020. 
 
You asked the Plan to pay for the Decipher biopsy testing. You say that this should be covered as you were told 
Medicare pays for this test. The Plan denied your request. The Plan says that this test is only covered for men 
with low-risk to very low-risk prostate cancer. Since you have intermediate risk cancer, this testing is not 
covered. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is allowed for this testing for those with 
intermediate risk disease when the above referenced criteria 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 Decipher biopsy testing. Our reviewer 
says that the requested testing is shown to be medically reasonable and necessary. Our physician reviewer 
found the enrollee has prostate cancer with a Gleason score of 7 and a PSA of 10.3 who has not yet received 
any treatment. The enrollee's biopsy sample is larger than 5mm and he has unfavorable intermediate disease. 
His life expectancy is greater than 10 years. All criteria for this testing as noted in the LCD are met. 
 
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 Decipher biopsy testing have not been met. Therefore, we decided that the 
Plan has to pay for the Decipher biopsy testing provided on April 21, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99350) provided on October 14, 2019 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the billed code does not appropriately reflect the 
services provided by the resident nurse. 
 
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 99350 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval 
history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a 
significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99350 is not supported in the record. Specifically, the billed code does not 
appropriately reflect the services rendered by the resident nurse. Additionally, a home visit cannot be billed by 
a physician unless the physician was actually present in the beneficiary's home. Based on this information, we 
decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the 
Plan does not have to pay for the home visit (99350) provided on October 14, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that your doctor said that you need to 
get this procedure done on both eyes rather than just one and you would like to request reconsideration of the 
denial. The Plan denied your request. The Plan says this procedure is considered experimental or 
investigational and is therefore not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance 
(64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 this patient appears to require additional short-term acute care services as they are 
improving with current treatment, however, it is unlikely that they will require more than an additional 25 days 
of daily physician intervention for the wounds or other medical conditions, based on the records. The patient 
does not require services at the LTACH that are not already available and covered at the current facility. There 
are no services at the LTACH that the patient requires that are not already available and covered at the current 
facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 
Transfer to a lower level of care may be considered soon. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 this patient appears to require additional short-term acute care services but remains 
fairly unstable, requiring high flow oxygen and BiPAP with possible need for thoracentesis based on recent 
notes. The patient does not require services at the LTACH that are not already available and covered at the 
current facility. There are no services at the LTACH that the patient requires that are not already available and 
covered at the current facility. Therefore, this request for LTACH services will be considered not medically 
necessary at this time. Ongoing care at the current facility appears most appropriate for now. Transfer to a 
lower level of care may be considered if able to become more stable. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 this patient appears to require additional short-term acute care services as they are 
improving, however, it is unlikely that they will require more than an additional 25 days. The patient does not 
require services at the LTACH that are not already available and covered at the current facility. There are no 
services at the LTACH that the patient requires that are not already available and covered at the current facility. 
Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to 
a lower level of care may be considered soon. 
 
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 LTACH services.