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

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of chest (71250). 
 
You asked the Plan to pre-approve CT scan of chest. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan of chest. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the medical necessity for a CT of the 
chest is not established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of chest have not been met. Specifically, there is no indication that a 
CT scan is medically necessary or reasonable for your diagnosis. This means the service is not covered. 
Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of chest 
(71250).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on September 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on September 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs and needles described by CPT 
code A9270 and the sales tax described by CPT code S9999 provided on July 7, 2020. 
 
You asked the Plan to pay for CPT codes A9270 and S9999. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the self-administered drugs and needles 
described by CPT code A9270 are not covered by Medicare. The Plan says sales tax is not covered by 
Medicare. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. 
 
The rules also say that a status code of N represents a non-covered service. The provider submitted a claim 
with CPT code A9270 to describe needles provided to you. This code has a status code of N and is not covered 
by Medicare. 
 
The rules also say contractors do not make any additional payment for sales taxes. Medicare does not make 
separate payment for sales tax. 
  
Therefore, we decided that the Plan does not have to pay for the self-administered drugs and needles described 
by CPT code A9270 and the sales tax described by CPT code S9999 provided on July 7, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 25, 2020, by non-
participating provider. 
 
You asked the Plan to pay for tall orthopedic walking boot (L4387). You say that the doctor told you to get 
one, and you didn't know you had to get it from a contracted provider. The Plan denied your request. The Plan 
says the denial was upheld due to the fact that durable medical equipment must be supplied from a provider 
that is participating with Medicare. 
 
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 participating provider with the Plan. The Plan had network 
providers available who could have provided 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 25, 2020, by non-participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angiography (75774) provided on August 6, 2020. 
 
You asked the Plan to pay for an angiography. You say that this code is included in CPT 75716. The Plan 
denied your request. The Plan says this is documented in the records. 
 
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 75774 is angiography, selective, each additional vessel 
studied after basic examination, radiological supervision and interpretation (List separately in addition to code 
for primary procedure). 
 
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 an angiography. Our reviewer says that the 
billing of this code is not supported. Our physician reviewer found the documentation does not support a 
decision for further study. CPT 75774 can be billed separately with CPT 75716, however, any further catheter 
placements in the lower extremities would be considered the completion of CPT 75716 if complete lower 
extremity imaging was not accomplished from the initial catheter placement. If a complete interpretation was 
completed and then a decision was made for further study, CPT 75774 would be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an angiography have not been met. Therefore, we decided that the Plan does not 
have to pay for an angiography (75774) provided on August 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient repositioning system. 
 
You asked the Plan to pre-approve a patient repositioning system. You say that you need the system for the 
safety, to prevent pressure sores and fractures, and to help aid in healing. The Plan denied your request. The 
Plan says any item that is used to make the activity easier for a caregiver is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that equipment used for the convenience of a person caring 
for the patient is not covered. Therefore, we decided that the Plan does not have to pre-approve a patient 
repositioning system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visits (99204, 99213, 
99215) provided from July 10, 2020, to July 29, 2020. 
 
You asked the Plan to waive the copayment for the office visits. You say that please correct billing due to no 
real, effective service being provided. You would expect your portion of the billable amount to be zero. The 
Plan denied your request. The Plan says the claim processed and the correct copayment was applied per the 
Evidence of Coverage 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for physician specialist services (including surgery second opinion, Medicare covered telehealth or 
urgently needed services).  
 
You have been asked to pay $45 copayment for the office visits. The office visits fall within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the outpatient office visits (99204, 99213, 99215) provided from July 10, 2020, to 
July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse the payment for the portable oxygen concentrator 
provided on June 25, 2020. 
 
You asked the Plan to reimburse the payment for the portable oxygen concentrator. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the denial of 
payment for these items is correct because purchased oxygen equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage and purchased oxygen equipment is statutorily non-covered.  
 
We looked at the file and Medicare rules. These items are not reimbursable when purchased. Based on this 
information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been 
met. Therefore, we decided that the Plan does not have to reimburse the payment for the portable oxygen 
concentrator provided on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an impact advanced recovery beverage (A9270). 
 
You asked the Plan to pre-approve this item. You say that an impact advanced recovery beverage is necessary 
to help support the enrollee's immune system after major surgery. The Plan denied your request. The Plan says 
nutritional supplementation is not a covered benefit under the enrollee's contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The item you asked the Plan to pre-approve is nutritional supplementation. Therefore, we decided that the Plan 
does not have to pre-approve an impact advanced recovery beverage (A9270).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the stationary oxygen system. We decided that the Plan does not 
have to pre-approve the portable oxygen.  
 
You asked the Plan to pre-approve the stationary oxygen system. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan says that additional and emergency oxygen systems 
are not medically necessary. 
 
We decided that the Plan has to pre-approve the stationary oxygen system.  
 
The Plan follows Medicare rules. Medicare rules say that home oxygen therapy is reasonable and necessary 
only if all of the specified conditions 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 pre-approve the stationary oxygen system. Our 
reviewer says that coverage criteria are met for home supplemental oxygen during sleep. The medical records 
include overnight oximetry that indicates that for 39 min of the night the oxygen saturation breathing room air 
was less than 88%.  The patient would therefore benefit from a stationary oxygen system such as an oxygen 
concentrator, which is considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the stationary oxygen system have been met. Therefore, we decided that the 
Plan has to pre-approve the stationary oxygen system.  
 
We also decided that the Plan does not have to pre-approve the portable oxygen. 
 
The Plan follows Medicare rules. Medicare rules say that a portable oxygen system is covered if the beneficiary 
is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during 
exercise. 
 
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 portable oxygen. Our physician 
reviewer found there are no oxygenation data during activity, so a portable oxygen concentrator is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the portable oxygen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the portable oxygen. 
 
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 pre-approveendovenous ablation therapy.You asked the Plan to pre-approveendovenous ablation therapy. You say that you needendovenous ablation therapy.The Plan denied your request. The Plan says documentation of a trial of compression stockingswas requested from your doctor but not received.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. There is no documentation of conservative therapy. Based on this information, we decided that Medicare rules for coverage of endovenousablation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveendovenous ablation therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dronabinol cap 2.5mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a pharmacy benefit with the plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dronabinol cap 2.5mg for 
the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam imaging you received on October 8, 2020. 
 
You asked the Plan to pay for the imaging. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. 
Cone beam imaging is not covered. Therefore, we decided that the Plan does not have to pay for the cone beam 
imaging you received on October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC) and transport lift. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not show that 
the enrollee's personal mobility deficit is impairing participating in mobility-related activities of daily living 
(MRADLs) and is not able to helped by use of a cane, walker, or manual wheelchair. She is able to ambulate 
short distances and has a transport equipment and assistance for out of the home. The services are not 
experimental/investigational in nature or cosmetic. The PWC is therefore not reasonable or medically 
necessary. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PWC have not been met. 
 
The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 
 
The requested transport lift is for use outside of the home. Medicare does not cover equipment for this use. 
 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC) and transport lift.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a 300 unit Botox dose for the enrollee. 
 
You asked the Plan to pre-approve the dosing. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the FDA-approved dosing for Botox for neurogenic bladder is a maximum of 200 
units every 12 weeks. 
 
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 dosing. Our reviewer says that the 
requesting dosing is medically reasonable and necessary. Our physician reviewer found the enrollee had 
ongoing symptoms after the last shot, with substandard results.  It is indicated to try the higher dosage instead 
of increasing the frequency of injections, as the provider does not feel comfortable giving the prior dose early 
(prior to twelve weeks). 
 
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 dosing have been met. Therefore, we decided that the Plan has to pre-
approve a 300 unit Botox dose for the enrollee.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says that previous treatment with Keytruda has not been effective. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage of Keytruda have been met. Our physician reviewer found Keytruda is indicated as a 
single agent for the treatment of recurrent or metastatic, head and neck squamous cell carcinoma, with disease 
progression on or after platinum-based chemotherapy per NCCN guidelines. The requested drug is being used 
for this indication. The fact that the enrollee has developed a new cancer does not represent original disease 
progression. Therefore, the requested drug is being used for a Medicare approved indication in a medically 
reasonable and appropriate fashion. There is no evidence that the drug is not safe or effective 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda (J9271).  
 
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 office visit rendered on August 18, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis code is not valid. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary 
diagnosis. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the office visit rendered on August 18, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete upper denture (D5110) provided October 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are requesting an appeal for $600 for 
complete denture. The Plan denied your request. The Plan says the annual maximum benefit limit has been 
exhausted. 
 
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. Page 4-50 of the health plan 
contract says the annual maximum is $1,000. Once the annual maximum is exhausted, any remaining charges 
are your responsibility. 
 
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 at this time. Therefore, we decided that the Plan does not have to pay 
for complete upper denture (D5110) provided October 21, 2020.