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

 
We decided that the Plan does not have to pay for the telehealth services provided on June 8, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth services. You say that the service provided to the enrollee was 
medically necessary and you would like the claim paid. The Plan denied your request. The Plan says that the 
rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the telehealth services provided on June 8, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74183 billed for date of service March 30, 
2022. 
 You asked the Plan to pay for procedure code 74183. You say that this service was medically necessary, and 
you do not have access to the hospital to see if the place of service is correct. The Plan denied your request. 
The Plan says this claim was billed with an incorrect place of service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. The POS code reported should reflect the actual 
setting where the beneficiary receives the face-to-face service. However, for services rendered to a patient who 
is registered inpatient, the correct POS code, regardless of where the face-to-face service occurs, is that of the 
appropriate inpatient POS code. 
 
We find that the POS code reported on this claim, code 22 (on campus, outpatient hospital), is not supported in 
the medical record. Specifically, the record shows that the enrollee was inpatient status from March 27, 2022, 
until April 4, 2022. This means that the inpatient POS code should be used in this case. Based on this 
information, we decided that Medicare rules for coverage of procedure code 74183 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 74183 billed for date of service 
March 30, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Palonosetron and Fosaprepitant. 
 
You asked the Plan to pre-approve Palonosetron and Fosaprepitant. You say that the records provided support 
the need for the drugs in dispute. The Plan denied your request. The Plan says that drugs to treat possible side 
effects cannot be approved until cancer treatment drugs have been approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Palonosetron and Fosaprepitant. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found the records show that 
the enrollee is to start Cisplatin (CDDP) and Gemzar. Our physician reviewer found that the drugs in dispute 
are medically reasonable and necessary as CDDP is high emetogenic. Our physician reviewer found that the 
use of the requested drugs in this setting are supported by the National Comprehensive Cancer Network 
(NCCN) compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Palonosetron and Fosaprepitant have been met. Therefore, we decided that the 
Plan has to pre-approve Palonosetron and Fosaprepitant.  
 
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 laboratory services provided on May 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan. The Plan also says that these services were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on May 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880). 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. The Plan denied your request. The 
Plan says this test is 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 a duplex scan of extracranial arteries. 
Our reviewer says that a duplex scan of extracranial arteries is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support the rationale for 
repeating this imaging study. Our reviewer found that the guidelines do not support a need for repeat carotid 
duplex scan extracranial bilateral study. Our physician reviewer also found that at this time, cardiac doppler 
imaging would not be considered medically appropriate and necessary in this enrollees 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 a duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous nerve ablation (Intracept). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure is medically necessary and 
supported by strong science. The Plan denied your request. The Plan says this procedure is 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intraosseous nerve ablation (Intracept).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 14, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right cervical facet joint 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 facet injections are covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right sub-occipital 
pain, right neck, right shoulder, and right axillary pain. There is no clinical indication that the C1 to C2 area is causing the enrollee's pain. She is status post C3 to C7 fusion, and most commonly, the adjacent segment of 
C2-C3, which is the most common cause of cervicogenic headache, has not been ruled out as the cause for her 
pain. The criteria for the facet injection are not met and the services are therefore not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right cervical facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on March 28, 2022, April 5. 2022, 
and May 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that you did not know the providers were OON 
providers. The Plan denied your request. The Plan says the rendering providers are OON providers and there 
were no approved authorizations. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visits provided on March 28, 2022, 
April 5. 2022, and May 2, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this will be able to help her with all her 
needs and allow for a successful recovery. The Plan denied your request. The Plan says the criteria for 
admission to the LTACH have not been met. 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. Our 
physician reviewer found the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a male vacuum erection system (L7900). 
 
You asked the Plan to pre-approve a male vacuum erection system. You say that you had the pump before, and 
the doctor requested another one because the previous one was worn. You would like the authorization to be 
reconsidered and approved. The Plan denied your request. The Plan says your request is not a covered benefit 
because there is no record you received a previous device, and new devices are non-covered by Medicare for 
dates of service on or after July 1, 2015. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a male vacuum erection system (L7900).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image 
guidance (CPT code 64625). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has completed two SI joint injections 
that had offered significant improvement, but the relief was short-lived. The Plan denied your request. The Plan 
says radiofrequency ablation of the sacroiliac joint nerves with imaging guidance is not supported by research. 
The Plan states the service is considered experimental and or investigational. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/ investigational approach because of the wide variation in 
efficacy reported in the literature. Therefore, the request is deemed not medically reasonable or 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve RFA, nerves innervating the SI joint, with image guidance (CPT code 64625).
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. You say that the records provided support the need for SNF care. 
The Plan denied your request. The Plan says the care needed is custodial in nature. 
 
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 documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Proton Beam Radiation Therapy (PBRT) (77525, 77014, G6002). 
 
You asked the Plan to pre-approve PBRT. You say that the enrollee has been diagnosed with malignant 
neoplasm of pelvis bones, sacrum and coccyx. The Plan denied your request. The Plan says that the procedure 
is not medically necessary. 
 
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 Proton Beam Radiation Therapy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the primary advantage of proton therapy is the ability to escalate the dose to the 
target while maintaining acceptable dose delivery to the normal critical tissues. In order to locally control sacral 
tumors (such as chordoma, or for the enrollee  solitary fibrous tumor) a higher-than-normal risk of spinal 
cord/cauda equina and bowel injury must be accepted. In the proton literature (with spinal cord maximum dose 
of 63 Gy and center cord dose of limit of 54 Gy), the actual reported risks of radiation induced spinal injury are 
low. The most recent NCCN guidelines acknowledge that proton therapy should be considered and that the 
doses needed to treat chordomas are high (and in excess of what the spinal cord and nerve roots are generally 
accepted to tolerate). Since this treatment parallels what would be offered for chordoma, proton therapy would 
be furnished in accordance with accepted standards of practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Proton Beam Radiation Therapy have been met. Therefore, we decided that the 
Plan has to pre-approve Proton Beam Radiation Therapy (PBRT) (77525, 77014, G6002).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this level of care is needed in order to 
have a successful recovery. The Plan denied your request. The Plan says the level of care provided in the 
LTACH setting is not medically necessary. 
 
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. Our 
physician reviewer found the enrollee requires short-term additional acute care hospital services that can be 
safely administered at the current facility. The enrollee does not require services at the LTACH that are not 
already available at the current facility. Transfer to the LTACH is not medically necessary as it would not be 
clinically advantageous at this time. 
 
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that please reconsider this claim for 
benefits and services as ordered by the enrollee's physician as medically necessary. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 
 
 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 (E0675).