Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ascent injection. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic right shoulder 
pain. She underwent a right shoulder steroid injection without significant pain relief. The requested Ascent 
injection is not the standard of care for the enrollee's condition and is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Ascent injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy (77520, 77522, 77523, 77525x 35). 
 
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the need for proton therapy for advanced lung cancer needs to be established on an 
individual basis with a plausible rationale as to why proton therapy is needed in lieu of more standard 3D 
conformal radiation or intensity-modulated radiation therapy (IMRT). While medical records are provided, 
there is no history and physical from a radiation oncologist (or any other provider) and no letter of appeal from 
a radiation oncologist describing the need for radiotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy (77520, 77522, 77523, 77525x 35).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar epidural injections (64483). 
 
You asked the Plan to pre-approve lumbar epidural injections. You say that this is medically necessary. The 
Plan denied your request. The Plan says the record does not show you have failed conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar epidural injections are indicated when 
there has been a failure of four weeks (counting from onset of pain) of non-surgical, non-injection care, which 
may include appropriate oral medication(s) and physical therapy/modalities to the extent tolerated. 
 
We looked at the file and Medicare rules. The submitted medical records do not include documentation of four 
weeks of non-surgical, non-injection care. Based on this information, we decided that Medicare rules for 
coverage of lumbar epidural injections have not been met. Therefore, we decided that the Plan does not have to 
pre-approve lumbar epidural injections (64483).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androgel Gel (J3490). 
 
You asked the Plan to pre-approve Androgel Gel. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Androgel Gel (J3490).  
 
Benefits for Androgel Gel 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical assessment does not implicate the facet joint as the putative source of pain. 
 
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 injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation indicating that the facet joint is the main source of pain. The requested facet 
injection is not medically necessary or reasonable. 
 
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 a facet injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate has not been 
established. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental for use in fusion surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for the biopsy provided. 
 
You asked the Plan to waive the co payment for the biopsy. You say that you've never had to pay for these 
biopsies before. You say that this is an outpatient procedure not in the hospital. The Plan denied your request. 
The Plan says the co payment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
co payment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center, including but not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay a $100 co payment for the biopsy. The biopsy falls within the "Outpatient Surgery 
and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 
benefit category. The biopsy is considered a surgical procedure that was billed by the hospital. 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 co payment for the biopsy provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an amniotic fluid injection. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pain and tendinitis of 
the right shoulder. The amniotic fluid injection is considered experimental/investigational at this time and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an amniotic fluid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to you on July 2, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider does not 
participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. The requested provider is not enrollee in the Medicare program. 
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 provided to you on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 9, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says to receive 
payment for covered Medicare items or services from either Medicare or a Medicare beneficiary, a provider or 
supplier must be enrolled in the Medicare program. This provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 17, 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 has network providers 
available who can provide 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 the enrollee by an out-of-network provider 
on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 25 extractions (D7140 x25). 
 
You asked the Plan to pre-approve the extractions. You say that the extractions are medically necessary. The 
Plan denied your request. The Plan says extraction of teeth is not a covered benefit. The Plan also says that the 
enrollee does not carry the optional dental coverage. 
 
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 25 
extractions (D7140 x25).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from December 4, 2020, 
forward. 
 
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from December 4, 2020, forward.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four monitoring (95937) provided on April 16, 2020 
 
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method.  
 
We find that CPT code 95937 is not supported in the record. Specifically, the record indicates that train of four 
monitoring was rendered.  This does not meet CMS guidelines for CPT code 95937. Additionally, train of four 
monitoring is considered integral to the primary procedure and not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. 
Therefore, we decided that the Plan does not have to pay for train of four monitoring (95937) provided on April 
16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular ablation. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee pain 
from osteoarthritis. Genicular nerve blocks and genicular nerve ablation are considered investigational and not 
medically necessary for the treatment of chronic knee pain. The services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular ablation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 10, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 10, 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 the ambulance services provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on July 16, 
2020. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you were not informed there 
would be a fee outside of your coverage for the hospital. You say that you don't know what this charge is for. 
The Plan denied your request. The Plan says the copayment applied correctly. 
 
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 a $35 
copayment for each specialist visit.  
 
You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the 
"Physician/Practitioner services, including doctor?s office visits" benefit category. The records show the visit 
was for a consultation for pain management. 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 
specialist visit provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis, aspiration and/or injection provided June 
5, 2020. 
 
You asked the Plan to pay for the arthrocentesis. You say that due to obesity of the knee or difficulty aspirating 
synovial fluid and uncertainty of the exact location of the needle tip ultrasound guidance was used. Please 
reprocess 20611 for payment. The Plan denied your request. The Plan says the records do not support the 
service billed. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (e.g., shoulder, hip, knee or subacromial bursa with ultrasound guidance, with permanent 
recording and reporting). 
 
We find that CPT code 20611 is not supported in the medical record. Specifically, the documentation submitted 
do not contain documentation of permanently recorded images to support the billed charge. Based on this 
information, we decided that Medicare rules for coverage of the arthrocentesis have not been met. Therefore, 
we decided that the Plan does not have to pay for the arthrocentesis, aspiration and/or injection provided June 
5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for complicated pneumonia.  The enrollee 
was intubated/ventilated and extubated several times before finally receiving a tracheotomy. The enrollee 
appears to be neurologically intact and is tolerating ventilator weaning. There is no evidence that the enrollee 
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 enrollee can remain at the current 
ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower 
level of care for any ongoing long term care needs. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.