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

 
We decided that the Plan does not have to pay for the services (CPT 73070) provided on November 25, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 73070 is Radiologic examination, shoulder; complete, 
minimum of 2 views. 
 
We asked our coding 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 use 
of CPT code 73070 is not supported by the records provided. Our coding reviewer found that the office visit 
does not include how many views were taken to support CPT 73070. 
 
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 (CPT 73070) provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a cervical vestibular evoked myogenic potential (cVEMP) test 
(92700). 
 
You asked the Plan to pre-approve a cVEMP test. You say that this is necessary to better inform the enrollee's 
treatment. The Plan denied your request. The Plan says that this is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 cVEMP test. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee suffers from dizziness and imbalance. cVEMP is known to be very useful when diagnosing 
superior semicircular canal dehiscence. Multiple literature sources support the use of this test and do not state 
that the test is experimental or investigational. The results from the test are open to interpretation by the 
otolaryngologist treating the patient, and should be correlated clinically with the patient's history in order to 
determine a diagnosis. 
 
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 cVEMP test have been met. Therefore, we decided that the Plan has to pre-
approve a cervical vestibular evoked myogenic potential (cVEMP) test (92700).  
 
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 a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you lose your balance and you?re unable to 
bath yourself. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and routine electrocardiogram (ECG) to 
be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the out of network office visit and ECG. You say that the enrollee was 
scheduled for an appointment on October 12, 2020. The Plan denied your request. The Plan says no 
information was presented to indicate that the requested services are an emergency or that they cannot be 
supplied by an in-network provider. 
 
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 
an office visit and routine electrocardiogram (ECG) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit for new patient (99202, 99213) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the office visit for new patient. You say that the rating of the provider is 
very good. The Plan denied your request. The Plan says an in-network provider can provide the requested 
services. 
 
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 office visit for new patient (99202, 99213) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve syringes for a self-administered drug. 
 
You asked the Plan to pre-approve syringes. You say that you need these to inject B12. The Plan denied your 
request. The Plan says that this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies used with self-administered drugs are 
not covered. We looked at the file and Medicare rules. Therefore, we decided that the Plan does not have to 
pre-approve syringes for a self-administered drug.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power wheelchair (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says that coverage criteria is not met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patient?s condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the Powerchair is medically necessary. Our physician reviewer found there is ample evidence based 
on the Physical Therapy evaluation, and evaluation of comorbid conditions, which demonstrate sufficiently that 
the enrollee is unable to propel a standard wheelchair. 
 
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 power wheelchair have been met. Therefore, we decided that the Plan has to pre-approve a power 
wheelchair (K0823).  
 
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 a spinal cord stimulation (SCS) trial. 
 
You asked the Plan to pre-approve the SCS trial. You say that the enrollee has not had success with any other 
treatments, and this should be tried. The Plan denied your request. The Plan says the enrollee does not have a 
diagnosis for which SCS can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that SCS may be covered for enrollees with intractable 
back pain when used as a late if not last resort.  
 
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 SCS trial. Our reviewer says that 
the requested SCS trial is not shown to be medically reasonable and necessary. Our physician reviewer found 
this enrollee has chronic low back pain with radiation in both of her legs. She is taking Norco and Ibuprofen. 
She has had physical therapy and a Home exercise program. She has had a caudal epidural injection and 
Lumbar nerve destructions. She has not had spine surgery and documented multi-level disc degenerative 
disease. She does not have an evidence-based indication for a SCS trial. 
 
The patient has multiple other modalities and consultations available to her (e.g. acupuncture, surgical 
intervention). This is not being used as a late/ last resort modality. The request 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 SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulation (SCS) trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the post removal (D2955). 
 
You asked the Plan to pre-approve the post removal (D2955). You say that the tooth has been broken since 
January and you are unable to eat. You say that the old post needs to be removed so the new post and crown 
can be put in. The Plan denied your request. The Plan says the service 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
post removal (D2955).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HYALGAN. 
 
You asked the Plan to pre-approve HYALGAN. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 HYALGAN. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has pain related to osteoarthritis of the right knee, diagnosis confirmed with 
imaging studies. The enrollee has failed conservative treatment. The documentation does not support that the 
enrollee has had a trial of Durolane, Gelsyn-3, and Synvisc/Synvisc-One. The documentation does not support 
that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HYALGAN have not been met. Therefore, we decided that the Plan does not 
have to pre-approve HYALGAN.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 physical therapy visits. The Plan denied your request. The Plan says 
additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 8 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee appears to be at his baseline with regard to 
function and endurance can be improved with a maintenance program with nursing and caregivers. Our 
reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide 
ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
You asked the Plan to pre-approve the core build up. The Plan denied your request. The Plan says core build up 
is not listed as a covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a TENS unit (E0720). 
 
You asked the Plan to pre-approve the TENS unit. You say that you would like reconsideration because you are 
in pain and this equipment is medically necessary. The Plan denied your request. The Plan says there is no 
evidence or documentation that you are participating in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for chronic low back pain is only 
covered when the beneficiary is enrolled in an approved clinical study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS unit have not been met. The record does not show that you are enrolled in an approved 
clinical study. Therefore, we decided that the Plan does not have to pre-approve a TENS unit (E0720).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of a femoral fracture (27506) provided on July 
18, 2019. 
 
You asked the Plan to pay for the treatment of a femoral fracture. You say that this is documented in the 
records. The Plan denied your request. The Plan says this 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 27506 is open treatment of femoral shaft fracture, with or 
without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking 
screws. 
 
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 treatment of a femoral fracture. Our 
reviewer says that the use of this code is not supported. Our physician reviewer found the operative report 
documents a Proximal femoral replacement, left total hip arthroplasty, application of a strut graft to the left 
femur, not the repair of a fracture. 
 
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 treatment of a femoral fracture have not been met. Therefore, we decided 
that the Plan does not have to pay for the treatment of a femoral fracture (27506) provided on July 18, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the crown for tooth #9. 
 
You asked the Plan to pre-approve the crown for tooth #9. You say that you were told by two dentists that you 
need to replace the crown because it has a crack and is starting to come loose. The Plan denied your request. 
The Plan says that it is not medically necessary to replace the crown on your tooth. 
 
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 the crown for 
tooth #9 when the services are medically necessary and reasonable. 
 
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 crown for tooth #9. Our reviewer 
says that the criteria for coverage has been met. Our physician reviewer found that due to the presence of 
recurrent caries and a loose crown, restoring tooth #9 with a new crown meets the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown for tooth #9 have been met. Therefore, we decided that the Plan has 
to pre-approve the crown for tooth #9.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on August 28, 2019. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360? and NEXT-Generation?) 
requires use of CPT 81479 (for the entire multi-test panel). 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on August 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OnabotulinumtoxinA (Botox) for migraines. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says this drug is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is covered for the above indications. 
 
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. Our physician reviewer found that the 
provider noted the headaches "do not have migrainous clear features." Additionally, there are not details 
supporting symptoms refractory to conventional therapies. Finally, the enrollee has been receiving Botox 
injections since February 2020. Documentation does not outline a significant decrease in number or frequency 
of headaches. The guidelines are not supported and 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve OnabotulinumtoxinA (Botox) for migraines.
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 the supervision services required can be safely received in a different setting, for 
example: home with home health, in residential care, or home with close follow-up with the doctor. 
 
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 services or therapy, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse/therapist is not required to safely and effectively 
provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not 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 or in the home with home health services appears 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).