Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Myobloc. 
 
You asked the Plan to pre-approve Myobloc. You say that after failing to improve on other medications she 
started to have improvement with periodic injections of Botox. You say that she is a secondary non-responder 
to Botox so it is medically necessary to continue to receive injections of Myobloc. The Plan denied your 
request. The Plan says that Myobloc does not have an FDA indication for the member's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Myobloc. Our reviewer says that that 
the elements of the coverage criteria are satisfied, and the requested service is recommended. Our physician 
reviewer found that the record indicates the enrollee has a diagnosis of Meige syndrome or idiopathic cranio-
facial dyskinesia. Although the FDA has not stated that the requested drug is indicated for the enrollee's 
condition, the Wisconsin Physicians Service Insurance Corporation, a CMS Medicare Contractor (MAC), has 
issued a provisional affirmation for the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myobloc have been met. Therefore, we decided that the Plan has to pre-approve 
Myobloc.  
 
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 an advanced leg pump device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no documentation of edema extending to the chest, trunk and/or abdomen, and 
there has not been at least a four week trial of a basic pump. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have lymphedema of the chest, trunk, or abdomen on the medical progress notes. 
The enrollee does not have unique characteristics that would indicate the segmented pump over a standard 
pump on the submitted documentation. The documentation does not reveal a four week trial of the standard 
pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an advanced leg pump device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 10, 2021. 
 
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 an appropriate modifier was not 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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on July 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 6, 
2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 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, we have confirmed that code 74181 
is a column II code to column I code 74183. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hands-free assistive device for phone calls. 
 
You asked the Plan to pre-approve a hands-free assistive device for phone calls. You say that this device is 
medically necessary as you cannot use a standard telephone. The Plan denied your request. The Plan says 
required documentation is missing that supports this request. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a hands-free assistive device for phone 
calls. have been met. In this case, the Plan requested medical documentation from your primary care physician 
that supports the requested equipment. No information was returned but there was an indication that a 
scheduled appointment was upcoming where this would be discussed. Without this medical documentation, the request cannot be determined as being medically reasonable and necessary. Therefore, we decided that the Plan 
does not have to pre-approve a hands-free assistive device for phone calls.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Energix-B vaccine. 
 
You asked the Plan to pre-approve an Energix-B vaccine. You say that this is medically necessary. 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 Hepatitis B Vaccines are covered under 
Medicare Part B when a Medicare beneficiary is at high or intermediate risk of contracting hepatitis B.  
 
Records do not show that you have been injured or directly exposed to Hepatitis B. Insufficient clinical 
documentation was provided to show that you fall within a covered high or intermediate risk population as 
defined by Medicare rules. Therefore, we decided that the Plan does not have to pre-approve an Energix-B 
vaccine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk or stand and need 
rehabilitation. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your rehabilitation needs can be met at a lower intensity setting such as in-home or 
outpatient 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the member has not tried and failed zoledronic acid. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary. The patient has not tried and failed zoledronic acid. The provided 
records do not describe any suggestion that the patient would not tolerate zoledronic acid as it is injectable and 
not oral, nor was there any noted contraindication to such. There is no evidence that the zoledronic acid would 
be less effective than Prolia for the patient's condition. Our physician reviewer found that the enrollee's 
condition does not meet step therapy criteria for Prolia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on October 26, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this 
service to be covered. The Plan denied your request. The Plan says this service exceeds the maximum allowed 
per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on March 4, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 7, 2021. 
 
You asked the Plan to pay for the services provided. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the billed codes 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 code. 
 
The claim billed a place of service as an independent laboratory. We looked at the file and the rules. The 
records do not indicate the specimen was obtained at the independent laboratory. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the lab services provided on June 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for measurement of blood oxygen level (94761) provided on 
June 25, 2019. 
 
You asked the Plan to pay for measurement of blood oxygen level. You say that this billed charge is accurate 
and appropriate. The Plan denied your request. The Plan says this service has a status indicator of T on the 
CMS National Physician Fee Schedule (NPFS) Relative Value (RVU) file. This means this service is always 
bundled into another payable physician service. In this case, it is bundled with 96375, which was billed on the 
same day by the same provider. 
 
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, CPT Code 94761 has a status code of T under the NPFS. There are RVUs and payment amounts 
for these services, but they are only paid if there are no other services payable under the physician fee schedule 
billed on the same date by the same provider. If any other services payable under the physician fee schedule are 
billed on the same date by the same provider, these services are bundled into the physician services for which 
payment is made. 
 We find that CPT code 94761 is not supported in the medical record. Specifically, other physician services 
were billed and paid on the same date by the same provider. Therefore, payment for this service is bundled into 
the physician services for which payment was made. Based on this information, we decided that Medicare rules 
for coverage of measurement of blood oxygen level have not been met. Therefore, we decided that the Plan 
does not have to pay for measurement of blood oxygen level (94761) provided on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214, 99204) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that during a follow-up appointment, your surgeon 
observed aorta abnormalities that he believes this provider is particularly qualified to investigate, and you are 
now having issues that are affecting your health and need to be addressed. The Plan denied your request. The 
Plan says this provider is not a network doctor, and they will approve the office visit with a network doctor. 
 
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 (99214, 99204) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Select MDx test provided to the enrollee on June 9, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no documented significant interval increase in prostate specific antigen (PSA) 
level. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found though the initial results are encouraging, there is an overall paucity of sufficient evidence currently 
available in the peer-reviewed literature to evaluate the clinical utility of this test. Only two studies have been 
published to date regarding the performance of SelectMDx. Of the three cohorts studied among the two publications, the first two were utilized to establish analytical validity, and the third was utilized for clinical 
validity. SelectMDx needs to be tested in larger and heterogeneous populations in diverse clinical settings to 
further assess the clinical validity and clinical utility of this test. There was no documented significant interval 
increase in prostate specific antigen (PSA) level. The review has determined the services at issue in this case 
medically reasonable and 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Select MDx test provided to the enrollee on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 28, 
2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on September 28, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), prophylaxis (D1110), and preventive procedure (D1999) provided on July 8, 2021, and October 
25, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, prophylaxis, and 
preventive procedure. You say that you understand that you have two free dental cleanings per year. You also 
say that you were surprised when you received bills because you thought you had a free cleaning. The Plan 
denied your request. The Plan says the preventive procedure is not a covered benefit. The Plan also says that 
you have exceeded the benefit maximum. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. The Plan contract also says that the Plan offers a $2,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on June 23, 2021 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-
ray (D0220), prophylaxis (D1110), and preventive procedure (D1999) provided on July 8, 2021, and October 
25, 2021.  
 
Please Note: The Plan contacted the providers office regarding the charge for the preventive procedure (D1999). The 
provider has agreed to write off the charge and you are no longer being billed for the preventive procedure 
(D1999).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 2, 2021. You asked the Plan to pay for the services provided. 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 code. 
 
We looked at the file and the rules. The claim billed a place of service as an independent laboratory. The 
records do not indicate the specimen was obtained at the independent laboratory. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on March 2, 2021.