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

We decided that the Plan does not have to pay for the x-ray exam of sinuses provided on May 18, 2020. 
 
You asked the Plan to pay for the x-ray exam of sinuses. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says according to their policy, which is based on the American Academy of 
Otolaryngology, the use of routine diagnostic imaging is not recommended for patients with allergic rhinitis. 
 
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 70220 is Radiologic examination, sinuses, paranasal, 
complete, minimum of 3 views.  
 
In this case the code billed is not appropriate for the enrollee's diagnosis. The Plan states a corrected claim 
would be reviewed. Based on this information, we decided that Medicare rules for coverage of the x-ray exam 
of sinuses have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray exam of 
sinuses provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan has to pay for Belt, strap, sleeve, garment, or covering, any type provided on May 1, 
2020. 
 
You asked the Plan to pay for Belt, strap, sleeve, garment, or covering, any type (A4467). You say that you are 
being billed by your doctor's office for the orthosis. The Plan denied your request. The Plan says that you will 
not be held responsible for the cost of the orthosis. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for Belt, strap, sleeve, garment, or covering, any type (A4467) by a contract provider. The 
file does not show that the Plan provided notice that Belt, strap, sleeve, garment, or covering, any type (A4467) 
would not be covered. Under Medicare rules, this means Belt, strap, sleeve, garment, or covering, any type 
(A4467) is considered approved by the Plan. Therefore, we decided that the Plan has to pay for Belt, strap, 
sleeve, garment, or covering, any type provided on May 1, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (root canal). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. 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 specifically 
excluded from coverage by the dental plan. Therefore, we decided that the Plan does not have to pre-approve 
endodontic therapy (root canal).
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on January 28, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says per the Medicare provider database, you are not a Medicare payment eligible provider.
We overturned the Plan's denial stating the testing was ordered by the enrollee's contract provider. The
Plan requested a reopen and stated that whether the testing was ordered by a Plan provider is not of issue
because the Plan cannot make payment to providers who are not Medicare eligible providers.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment
may be made for items or services provided directly by a physician or practitioner who has opted out of the
program or who is not eligible to accept Medicare payment structures.

The services at issue in this appeal were rendered by a provider who is not a Medicare eligible provider.
Whether or not the services were ordered by a Plan provider is not of issue as the Plan must be able to pay the
out of network provider the testing request was sent to. We have confirmed the NPI submitted by the provider
is not listed as Medicare eligible. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for partial prothrombin time services provided to the enrollee on 
February 5, 2020. 
 
You asked the Plan to pay for the services. You say that per your coding specialist, the claim is correct as 
billed. The Plan denied your request. The Plan says CPT 85730 has not met the associated diagnosis 
relationship. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the available records do not meet any of the required criteria. There is no documentation that these 
services were medically reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pay for partial prothrombin time services provided to the enrollee on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve the knee scooter.. You say that the knee scooter is medically necessary. The 
Plan denied your request. The Plan says the knee scooter is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that crutch substitutes are not covered.  
 
We looked at the file and Medicare rules. The requested item is not a covered benefit. Based on this 
information, we decided that Medicare rules for coverage of the knee scooter. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because PET scans are not 
approved for routine cancer check-ups. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found this 
request is for surveillance, however Computed Tomography (CT) of the chest every 6 months for 2 to 3 years 
is recommended for surveillance instead. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Positron Emission Tomography (PET) scan.
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 for the enrollee. 
 
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 the enrollee can safely receive the services needed in other settings. 
 
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. There 
is no evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. 
The documentation does not support that there is a need for an intensive therapy program with 3 hours a day 
and an interdisciplinary approach to rehab care. With the enrollee's cognitive problems, and max assist 
functional level, she will not make a significant functional progress in a predicted period with no medical 
complexity in an IRF. The enrollee's rehab needs can be met in an alternate, less intense setting. Our physician 
reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that you would like the plan to reconsider 
their 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 a CardioMEMS 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 has NYHA class III congestive heart failure with preserved LV ejection 
fraction (LVEF 55-65%) requiring hospitalization. In this circumstance therapy change based on data obtained 
from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission 
compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial 
calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time 
according to leading authorities and not recommended in current guidelines for the treatment of heart failure. 
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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound examination provided on May 17, 2020. 
 
You asked the Plan to pay for ultrasound. You say that this procedure was rendered in the appropriate place of 
service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
the enrollee was a hospital inpatient during this date of service and therefore the claim was not billed with the 
appropriate Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital inpatient 
or outpatients, the inpatient or hospital Place of Service (POS) code respectively is reported as the Place of 
Service.  
 
We looked at the file and Medicare rules. This claim was billed with Place of Service (POS) code 22 - 
indicating an outpatient hospital setting - however the enrollee was a hospital inpatient on this date of service. 
Therefore, the Place of Service (POS) code 22 is not appropriate for this claim. Based on this information, we 
decided that Medicare rules for coverage of ultrasound have not been met. Therefore, we decided that the Plan 
does not have to pay for an ultrasound examination provided on May 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fifteen (15) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transport to 
medical appointments. The Plan denied your request. The Plan says that this request exceeds your benefit limit. 
 
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 forty-eight (48) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan does not have to cover routine transportation over the benefit maximum of forty-eight (48) routine 
transportation trips. Therefore, we decided that the Plan does not have to pre-approve fifteen (15) additional 
routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has no contractual obligation to cover services that are not covered by 
Medicare. 
 
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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgery for ruptured colon. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
does document a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. You say that the services 
are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 a PET CT scan from the skull base to 
mid-thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found the 
enrollee has had 3 separate and distinct primary cancers. Of note the enrollee was found to have a metastatic 
focus in the T7 vertebral body proven via biopsy on August 20, 2020 for which he has completed a course of 
radiation therapy. The requested PET/CT should be approved since it will occur after the completion of his 
radiation therapy for the T7 vertebral metastasis. 
 
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 PET CT scan from the skull base to mid-thigh have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815).  
 
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 radio frequency venous ablation of DLGSV, DLSASV, 
LPV (36475 x3) and radio frequency venous ablation of the same extremity, separate incision (36476 x2) 
 
You asked the Plan to pre-approve radio frequency venous ablation. You say that you feel that this procedure is 
the best option for this enrollee to greatly improve their quality of life and eliminate symptoms. The Plan 
denied your request. The Plan says the records do not support that the enrollee meets the Medicare criteria. 
 
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 radio frequency venous ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is status post bilateral knee replacement and underwent an 
epidural lumbar procedure in 2018.  She is status post left greater saphenous vein ablation, left small saphenous 
vein ablation, right greater saphenous vein ablation, right small saphenous vein ablation, right perforator 
ablation, and left perforator ablation.  With respect to her vascular status she is documented on to have no 
difficulties with activity of daily living and no limitations due to symptoms.  It is unclear from the medical 
record when concerted efforts at conservative treatments were attempted recently.  Her edema is described as 
either being plus one or trace.  Therefore, the documentation does not meet coverage criteria or support the 
medical necessity/appropriateness of the 5 additional ablative procedures on her legs being requested for 
coverage.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radio frequency venous ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radio frequency venous ablation of DLGSV, DLSASV, LPV (36475 x3) 
and radio frequency venous ablation of the same extremity, separate incision (36476 x2)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0483, 80307) provided on July 3, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the drug test. You say that the treatment was prudent and necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained by the facility or the provider; 
therefore, payment has been correctly denied. 
 
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 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. 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 drug test (G0483, 80307) provided on July 3, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc injection (3 units). 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary due to continued right 
knee pain. The Plan denied your request. The Plan says there must be six months between 
viscosupplementation. 
 
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 the injection. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found per the review she 
last received vicosupplementation on 7/7/2020. Per the coverage guidelines there must be six months between 
viscosupplementation. The review has determined that the requested Orthovisc injection in this case is not 
medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orthovisc injection (3 units).