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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due 
to insufficient evidence of efficacy. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is considered experimental. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy (EBT). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that for this case, there are no compelling reasons offered for why stereotactic radiosurgery (SRT) would 
be needed over more standard approaches of radiation delivery.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve high dose rate electronic brachytherapy (EBT).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Therapy (PBT) (77525). 
 
You asked the Plan to pre-approve PBT. You say that PBT is medically necessary. The Plan denied your 
request. The Plan says there is no current research showing that the enrollee's type of cancer responds better to 
the requested type of treatment than the type of treatment the Plan can approve. The enrollee does not meet 
approval of the requested therapy. 
 
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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the NCCN Panel believes no clear evidence supports a benefit or decrement to proton therapy 
over IMRT for either treatment efficacy or long-term toxicity. Conventionally fractionated prostate proton 
therapy can be considered a reasonable alternative to x-ray-based regimens at clinics with appropriate 
technology, physics, and clinical expertise. The guidelines further state, "The American Society for Radiation 
Oncology (ASTRO) evaluated proton therapy and created a model policy to support the society's position on 
payment coverage for proton beam therapy in 2014. This model policy was updated in 2017 and recommends 
coverage of proton therapy for the treatment of non-metastatic prostate cancer if the patient is enrolled in either 
an institutional review board (IRB)-approved study or a multiinstitutional registry that adheres to Medicare 
requirements for Coverage with Evidence Development (CED)." 
 
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 Therapy (PBT) (77525).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on August 31, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and was reported correctly. 
The Plan denied your request. The Plan says that the code used to report these services is not supported in the 
medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s), if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records provided support 
that 19 drug classes were tested in this case, including amphetamines, benzodiazepines, buprenorphine, 
cannabinoids (natural), cocaine, fentanyls, gabapentin (non-blood), heroin metabolite, methadone, 
methylenedioxyamphetamines, methylphenidate, opiates, opioids and opiate analogs, oxycodone, 
phencyclidine, pregabalin, skeletal muscle relaxants, tapentadol and tramadol. Based on this information, we 
decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan 
has to pay for definitive drug testing (G0482) provided on August 31, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) supplies 
billed with codes A7030, A7035, and A7031 for September 23, 2022. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 continuous positive airway pressure (CPAP) supplies 
billed with codes A7030, A7035, and A7031 for September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided on October 
1, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the items should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
proof of delivery is invalid. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery which support medical necessity for the supplies provided 
in this case. The tracking information provided does not include the enrollee's address and the packing slip 
provided does show the enrollee's address, however, it doesn't show that the delivery was successfully made to 
that address. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies 
(A4595) provided on October 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and a mattress 
(E0271). 
 
You asked the Plan to pre-approve a total electric hospital bed and mattress. You say that you disagree with the 
denial and are requesting reconsideration. The Plan denied your request. The Plan says the requested hospital 
bed has extra features that are not needed at home. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265) and a mattress (E0271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for procedure code 99051. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99051 is considered bundled and 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 procedure code. 
 
We find that procedure code 99051 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88344 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 88344. You say that this service was reported correctly. The Plan 
denied your request. The Plan says payment for code 88344 is bundled into payment for code 88321. 
 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 88344 
is a column II code to column I code 88321. 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 procedure code 88344 billed for date of service August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urea nitrate testing (84520 x3) provided on June 16, 2022. 
 
You asked the Plan to pay for the urea nitrate testing. You say that this service was medically necessary. The 
Plan denied your request. The Plan says one unit of this service was paid. The additional units exceed the 
allowed amount. 
 
The Plan must follow Medicare rules. Medicare rules say that blood urea nitrogen (BUN) testing is covered 
once per week for Chronic Renal Disease patients. 
 
We looked at the file and Medicare rules. Four units of this service were billed. Only 1 unit is eligible for 
coverage per week (a total of 13 per quarter). Based on this information, we decided that Medicare rules for 
coverage of the urea nitrate testing have not been met. Therefore, we decided that the Plan does not have to pay 
for urea nitrate testing (84520 x3) provided on June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says insufficient information was submitted to review the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the lab services have been met. 
Medical records were required to review the medical necessity of this claim. These records were requested by the Plan but were not received. We are unable to verify that criteria for coverage are met.  Therefore, we 
decided that the Plan does not have to pay for the lab services provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that based on the additional information available, the request does not meet the 
Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found as intensity-modulated radiation therapy was approved for this patient, and not disputed, it would be 
within accepted standards of medical practice to use IGRT with IMRT delivery due to the more conformal 
radiation delivery. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve image-guided radiation therapy (IGRT).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 8, 2022, to 
September 2, 2022. 
 
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 there is no valid plan of care from the physician. 
 
The Plan must follow Medicare rules. The rules say that the HHA must be acting upon a physician or allowed 
practitioner plan of care that meets the requirements of this section for HHA services to be covered. 
 
We looked at the file and Medicare rules. The file shows that there is no valid plan of care for the services at 
issue. 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 home health services rendered from 
August 8, 2022, to September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies billed with code A4595 for 
October 1, 2022. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 electrical stimulator supplies billed with code A4595 for 
October 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a peripheral nerve block (64624) provided on August 12, 
2022. 
 
You asked the Plan to pay for a peripheral nerve block. You say that this is supported in the records. The Plan 
denied your request. The Plan says this is not covered for the billed diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for code 64624 is limited to certain 
diagnosis codes. Code M17.11 is not listed as covered. 
 
We looked at the file and Medicare rules. The service at issue was billed with diagnosis code M17.11, which is 
not listed as a covered diagnosis. Based on this information, we decided that Medicare rules for coverage of a 
peripheral nerve block have not been met. Therefore, we decided that the Plan does not have to pay for a 
peripheral nerve block (64624) provided on August 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says therapy is available 
at a lower level of care, home care, assisted living or long-term care. Skilled nursing facility placement 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 in the Medicare rules section 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx next generation sequencing testing 
performed on August 23, 2022. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says the coverage criteria are not 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 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 that while the enrollee had metastatic cancer, the documentation does not sufficiently document that the 
enrollee decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
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 FoundationOne CDx next generation sequencing testing performed on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided for use during 
surgery on August 30, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided for use 
during surgery to prevent thrombotic events. The Plan denied your request. The Plan says this device was 
provided for a non-covered purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device provided for use during surgery on August 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427-RH, A0425-RH) provided on 
February 24, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services are supported in the medical 
records. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 3, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0427-RH, A0425-RH) provided on 
February 24, 2022.