Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for foot orthotics (CPT 29580) provided to the enrollee on August 14, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the billed procedure was denied because it was reported without a required anatomical 
modifier. 
 
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 29580 is "strapping; Unna boot." 
 
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 
services at issue in this case were supported by the medical records. Our coding reviewer found the procedure 
report documents an Unna boot on LT lower extremity. The Health Insurance Claim Form for date of service 
August 14, 2020 documents CPT 29580 LT modifier. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
foot orthotics (CPT 29580) provided to the enrollee on August 14, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM) receiver and supply 
allowance. 
 
You asked the Plan to pre-approve a CGM receiver and supply allowance.. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says that the requested items are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and 
necessary for enrollees with diabetes who meet criteria referenced 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 a CGM receiver and supply allowance.. 
Our reviewer says that the documentation supports that the requested items are medically reasonable and 
necessary. Our physician reviewer found the documentation supports that the enrollee has been using a blood 
glucose monitor and performing frequent testing. Given the frequency of dosing of insulin and frequency of 
insulin readings per day, the CGM supplies would be beneficial in the management of diabetes of the enrollee. 
Therefore, the enrollee meets criteria for the requested items. 
 
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 CGM receiver and supply allowance. have been met. Therefore, we decided 
that the Plan has to pre-approve a continuous glucose monitor (CGM) receiver and supply allowance.  
 
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 Musculoskeletal Surgery (CPT Code 22870 and 22869). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spinous process spacer is experimental. More research is needed to show safety and 
efficacy. There is no spinal instability. Hardware is not needed. Open laminectomy is gold standard. 
 
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 pre-approve Musculoskeletal Surgery (CPT Code 22870 and 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown provided on August 7, 2020 by an OON provider. 
 
You asked the Plan to pay for the crown. You say that employees at the provider's office told you that you were 
not OON. You also say that you are on limited resources and cannot pay this bill. The Plan denied your request. 
The Plan says this service was rendered by an OON provider. The Plan also says that payment cannot be made 
for services provided OON. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the crown 
provided on August 7, 2020 by an OON provider.
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 based on the documentation provided, the health plan?s denial of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH following surgery for limb ischemia 
that was complicated by a myocardial infarction and cardiogenic shock. The patient was intubated/ventilated, 
but has since been extubated and is no longer on a ventilator.  There is no evidence that the patient requires 
services that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, 
there is no advantage in transferring the enrollee to the LTACH. The patient can remain at the current ACH 
until such time no acute services are required. The patient can then be transferred/discharged to a lower level of 
care for any ongoing 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) injections. 
 
You asked the Plan to pre-approve the Keytruda treatment. You say that you believe this is necessary to treat 
your condition. The Plan denied your request. The Plan says you have had progression of your disease despite 
approval of Opdivo. Another drug in the same class cannot be approved in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda treatment. Our reviewer 
says that the documentation does not support that Keytruda is reasonable and necessary in this case. Our 
physician reviewer found the submitted information does not include results of PDL-1 testing. The submitted 
information has minimal information about prior treatment. It states she has had approval for Opdivo and that 
was changed to another treatment with unspecified chemotherapy. She has progression of the cancer on CT 
scans of 11/30/20 compared to scans of 3/4/19. 
 
The FDA approved use of Keytruda as second line monotherapy requires PDL-1 TPS at least 1% by an FDA 
approved test and progression on or after platinum-based chemotherapy. This information is not available to 
this reviewer. For the same reasons, the use is not supported in any of the CMS approved compendia. The 
NCCN compendium states that the requested use is not indicated if there has been progression on prior PD-
1/PDL-1 therapy. 
 
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 Keytruda treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Keytruda (pembrolizumab) injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 58952) provided to the enrollee on 
February 24, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says while the surgical services performed on 2/24/20 were medically necessary, the CPT code billed 
was not correct. 
 
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 58952 is "resection (initial) of ovarian, tubal or primary 
peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for 
debulking (ie, radical excision or destruction, intra-abdominal or retroperitoneal tumors)." 
 
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 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation submitted includes documentation of previous surgical intervention, therefore an initial code 
would not be appropriate in this case. A more appropriate code should be reported. 
 
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 surgical services (CPT 58952) provided to the enrollee on February 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening digital breast tomosynthesis, bilateral (77062) 
provided June 9, 2020. 
 
You asked the Plan to pay for the breast tomosynthesis. You say that kindly review the medical records and 
reprocess the claim. The Plan denied your request. The Plan says invalid procedure code for this service. 
 
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 77062 is Screening digital breast tomosynthesis, bilateral 
(List separately in addition to code for primary procedure). 
 
We find that CPT code 77062 is not supported in the medical record. Specifically, HCPCS code 77062 is 
assigned a status code I = not valid for Medicare purposes. The claim was billed with a CPT code which is 
invalid for usage with Medicare. Based on this information, we decided that Medicare rules for coverage of the 
breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for screening 
digital breast tomosynthesis, bilateral (77062) provided June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery pack for a CPAP machine. 
 
You asked the Plan to pre-approve a battery pack back up for a CPAP. You say that a battery backup is 
required in case there is a power outage. The Plan denied your request. The Plan says a battery pack for backup 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. Medicare does not cover a battery pack for precautionary measures such as possible power outages. 
Therefore, we decided that the Plan does not have to pre-approve a battery pack for a CPAP machine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 18, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for clinic visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 medical services provided on June 18, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 26, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that a referral from the 
member's primary care physician did not refer these 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 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 lab work provided on July 26, 2020 by an out of 
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT four-dimensional scan and SBRT to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says the recommend the member continues to follow-up with the in-network 
medical oncology and surgical oncology treating provider(s). 
 
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 provider at 
issue in this case is not a network provider with the Plan. 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 medical services. Our physician reviewer found treatment can be done with in-network 
provider. 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 medical services have not been met. 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 the medical services. Therefore, we decided that the Plan does not have 
to pre-approve CT four-dimensional scan and SBRT to be provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport (A0998, A0394, 
A0422) provided on July 8, 2020. 
 
You asked the Plan to pay for ambulance services without transport. You say that it was safer to not be 
transported to the hospital due to COVID-19. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 8, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services without transport (A0998, 
A0394, A0422) provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 7 additional extractions (D7140) provided on July 15, 
2020. 
 
You asked the Plan to pay for the dental services. You say that there was a limitation put on your healthcare 
that you needed. You say that the extractions took your life away. You also say that you are too embarrassed to 
go back to work. The Plan denied your request. The Plan says 2 extractions are covered per calendar year. The 
Plan also says that the frequency limit has been exceeded. 
 
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 frequency limit of 2 extractions per 
calendar year has been exceeded. The record shows that the Plan paid for 2 extractions that you received on the 
date of service. Therefore, we decided that the Plan does not have to pay for the 7 additional extractions 
(D7140) provided on July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment panel testing provided on 
August 7, 2020. 
 
You asked the Plan to pay for cardiovascular risk assessment testing. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is 
correct, because Medicare denies coverage for all cardiovascular risk assessment panels except the basic lipid 
panel. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
Although Medicare does cover certain cardiovascular disease screening tests, the tests billed are not among 
those which are covered for screening. Therefore, we decided that the Plan does not have to pay for 
cardiovascular risk assessment panel testing provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve lumbar ESI. You say that you have been getting these injections for two or 
three years and want this done as soon as possible. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the documentation does not support the medical necessity of 
this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that lumbar epidural steroid injections (ESI) are covered 
for the indications listed 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 lumbar ESI. Our reviewer says that you 
do not meet the criteria for coverage of this service. Our physician reviewer found you have a history of neck 
pain and knee pain, but there is no specific clinical rationale for the requested lumbar epidural. There are no 
positive findings on examination nor prior conservative treatments that have been tried and failed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on September 24, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that as your dentist was pulling out one 
tooth, the tooth next to it also came out. The Plan denied your request. The Plan says the maximum benefit 
allowance for comprehensive dental services for the contract year 2020 has been paid. 
 
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 Plan offers a $1,000 annual 
maximum per calendar year for comprehensive dental care services. The contract says that you are responsible 
for any amounts beyond the benefit limits. The record shows that you met the annual maximum benefit on 
September 24, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the resin-based composite provided on September 24, 2020.