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

 
We decided that the Plan does not have to pre-approve Proton Beam Treatment (PBT). 
 
You asked the Plan to pre-approve PBT. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Proton beam therapy will be considered medically 
reasonable and necessary for specific conditions. 
 
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 PBT. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found nothing in the case file suggests that these 
constraints cannot be met with the non-proton based treatment, and it is not plausible that proton therapy would 
be needed to meet these constraints. Proton therapy will almost always reduce dose to surrounding normal 
tissues. Simply demonstrating that proton therapy will reduce the low dose to normal tissues does not 
necessarily demonstrate that it is clinically needed relative to intensity-modulated radiation therapy (IMRT) 
though, as the reductions should be clinically meaningful, and reduce toxicity risks in a clinically meaningful 
manner. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on 
clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Treatment (PBT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #20, 22, 27, 29 (D6010), 
custom abutments on tooth #20, 22, 27, and 29 (D6057), and abutment supported crowns on tooth #20, 22, 27, 
29 (D6058). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says endosteal 
implants (D6010), custom abutments (D6057), and abutment supported crowns (D6058) are not covered by 
your dental benefits. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
endosteal implants on tooth #20, 22, 27, 29 (D6010), custom abutments on tooth #20, 22, 27, and 29 (D6057), 
and abutment supported crowns on tooth #20, 22, 27, 29 (D6058).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dermatology procedure to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a dermatology procedure. You say that you do not feel comfortable with the 
other in-network providers for this issue. The Plan denied your request. The Plan says there are many providers 
who are in-network. 
 
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 
a dermatology procedure 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 lab services provided on February 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says you 
have already used up all your trips for the 2022 benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy (procedure code 29823) provided to the 
enrollee on May 5, 2022. 
 
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 procedure code 29823-51-RT is not supported by the medical records records submitted. 
 
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 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies])." 
 
We asked our coder 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 reviewer found that the procedure detail cites there was 
tearing of the labrum which was debrided. The biceps stump was debrided inside the glenohumeral joint. There 
was extensive bursitis and synovitis in the subacromial space and a prominent subacromial spur. The 
arthroscopic shaver and radiofrequency ablation device was used to perform a subacromial bursectomy. The 
debris in the acromioclavicular joint was then debrided and the edges of the distal clavicle defined. Therefore, 
the records do support that CPT 29823 was actually rendered in this case.  
 
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 
surgical shoulder arthroscopy (procedure code 29823) provided to the enrollee on May 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance services coded 77001 provided on 
June 6, 2022. 
 
You asked the Plan to pay for the fluoroscopic guidance services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77001 is not supported in the medical record. Specifically, this code was billed for three 
units. Per the rules, code 77001 shall not be reportable separately during central venous access procedures. 
Based on this information, we decided that Medicare rules for coverage of the fluoroscopic guidance services 
have not been met. Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance 
services coded 77001 provided on June 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient medical surgical supplies and astigmatism 
correcting function of intraocular lens provided May 4, 2022 
 
You asked the Plan to pay for the outpatient vision services. You say that you had a friend who had the same 
procedure, and their health Plan paid the medical bill in full. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL. 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 $295 copay for each Medicare covered outpatient surgery at an outpatient hospital facility. If you get 
services that are excluded (not covered), you must pay for them yourself.  
 
 
You have been asked to pay $895 ($600 + $295) for the outpatient vision services. This item/service falls 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical services 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 pay for the outpatient medical surgical 
supplies and astigmatism correcting function of intraocular lens provided May 4, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart catheterization and ventriculography for the 
enrollee. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records show that the member has recently had an 8-week hospital stay with 
complete cardiac workup for coronary artery disease and had a normal stress test showing no coronary artery 
disease within the past few months. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a radionuclide stress test in 4/2022 was negative for ischemia. The medical records 
provided do not support the rationale for this invasive imaging study. The guidelines do not support a need for 
cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this patient's clinical management. 
 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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve heart catheterization and ventriculography for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 15, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they 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 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 an office visit provided on December 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5498 billed for date of service January 18, 
2022 to January 31, 2022. 
 
You asked the Plan to pay for procedure code S5498. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S5498 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5498 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S5498 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5498 billed for date of service January 18, 2022 to January 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided to the enrollee on July 7, 2022. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says the records do not show any signs or symptoms of deep vein thrombosis, chronic venous 
insufficiency, or need for venous mapping. 
 
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 scan. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the single office visit note provided lacks the detail and rationale to support the medical necessity of 
the study in question. The venous duplex appears to have been previously ordered as mention of the venous 
duplex is in the history of present illness. It is possible that documentation from an earlier visit during which 
the duplex ultrasound was ordered may have more detail as to the rationale for the study. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a duplex scan provided to the enrollee on July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan (78815) to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a PET CT scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested provider is out-of-network. 
 
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 
a positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) scan 
(78815) 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 laboratory services related to end-stage renal disease 
(ESRD) provided on April 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way transportation trips. 
 
You asked the Plan to pre-approve additional one-way transportation trips. You say that you need more 
transportation trips for doctor appointments. The Plan denied your request. The Plan says only 30 one-way trips 
per plan year for routine non-emergent visits is allowed. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 
  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one-way transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a spinal cord stimulator to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot. 
 
You asked the Plan to pre-approve Lupron Depot. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Lupron Depot. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried 
and failed the required drugs. There is no documentation provided indicating that the plans required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot.