Persius/hicric huggingface dataset:
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 due to your medical condition you are unable to care 
for yourself safely. The Plan denied your request. The Plan says the services that you need can be provided 
safely in another setting such as at a skilled nursing facility, home with home health services, or home with 
outpatient services. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says this 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found magnetic resonance imaging (MRI) shows foraminal stenosis and facet degenerative joint 
disorder. The cause of the enrollee's pain is unclear. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service September 
13, 2022 
 
You asked the Plan to pay for procedure code 99497. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99497 is bundled into 
payment for code 99291. 
 
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 99497 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99497 billed for date of service September 13, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoe supports to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve custom shoe supports. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received 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 
custom shoe supports to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 TissueNext (81479) provided on August 31, 2021. 
 
You asked the Plan to pay for Guardant360 TissueNext. You say that this test was medically necessary and was 
reported correctly. The Plan denied your request. The Plan says that the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 TissueNext 
have been met. Therefore, we decided that the Plan has to pay for Guardant360 TissueNext (81479) provided 
on August 31, 2021.  
 
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 the Tempus xF testing provided on October 29, 2022. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus xF testing provided on October 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98940). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are considered maintenance 
care which is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 
you do not meet criteria for coverage of the requested services. Our physician reviewer found that in this case, 
the record indicates that you have chronic back pain and require continued treatment to delay the need for 
surgery. The record provided does not establish that further clinical improvement of your condition is to be 
reasonably expected from the requested care. The elements of the coverage criteria are not satisfied. The 
requested services are not recommended. 
 
 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 chiropractic manipulative treatments (98940).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from October 24, 2022, to 
October 31, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that the enrollee's plan covers 12 visits. The 
Plan denied your request. The Plan says acupuncturists are not able to be reimbursed by Medicare. The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. The services at issue were provided by an acupuncturist without 
supervision of a Medicare approved provider. Based on this information, we decided that the rules for coverage 
of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services provided from October 24, 2022, to October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal cord stimulator (SCS). 
 You asked the Plan to pre-approve spinal cord stimulator. You say that you have been on pain killers for over 
20 years. You also say that you do not want any medication for pain. The Plan denied your request. The Plan 
says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered for certain 
indications. 
 
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 spinal cord stimulator. Our reviewer 
says that the documentation does not support that the requested services are not medically necessary. Our 
physician reviewer found you have had trials of Oxycodone, Gabapentin and Lyrica.  There is no 
documentation of pyschological evaluation. The documentation does not support that you have an indication as 
listed in the LCD. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal cord stimulator (SCS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit provided from 
August 26, 2022, to October 7, 2022 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you thought the 
services would be covered under chemotherapy. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay a $15 copayment for each specialist office visit. You have been asked to pay a 
total of $75 ($15 copayment x 5 visits = $75). These items/services fall within the physician/practitioner 
services, including doctor's office visits 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 waive the copayments 
for the specialist office visit provided from August 26, 2022, to October 7, 2022
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Herceptin Hylecta. 
 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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has triple positive 
ductal carcinoma in situ of the breast. The Food and Drug Administration (FDA) has not stated that the 
requested drug is indicated for the enrollee's condition and the Medicare-approved cancer drug compendia do 
not contain a supportive citation for its use. Step therapy coverage is not applicable, as the requested drug is not 
approved for the enrollee's condition. The services are not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Herceptin Hylecta.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the professional services for the administration of subcutaneous 
immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration 
calendar day in the individual's home identified with code G0069 provided on November 1, 2022. 
 
You asked the Plan to pay for procedure code G0069. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that this claim is inappropriately coded based on the CPT/HCPCS code 
definition or standard coding guideline. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that this claim is inappropriately coded based on the 
CPT/HCPCS code definition or standard coding guideline. However, the documentation does not include 
explanation on why this code was inappropriately billed. No Medicare rules were provided to support this 
denial. No other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the professional services for the administration of subcutaneous 
immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration 
calendar day in the individual's home identified with code G0069 provided on November 1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the most recent National 
Comprehensive Cancer Network (NCCN) guidelines for basal cell and squamous cell skin cancers explicitly 
state that there is insufficient long-term efficacy and safety data to support the use of electronic surface 
brachytherapy. The requested services are not the standard of care and are not reasonable or medically 
necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve electronic brachytherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96374 billed for date of service February 8, 
2022. 
 You asked the Plan to pay for procedure code 96374. The Plan denied your request. The Plan says payment for 
code 96374 is bundled into payment for code 78815. 
 
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 96374 
is a column II code to column I code 78815. 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 96374 billed for date of 
service February 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided August 9, 2022, billed with 
code 76706-26. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the service billed is not supported by the 
diagnosis. 
 
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 radiology services provided. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records did not describe the patient's smoking history or 
family history to be able to support this screening. 
 
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 radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services provided August 9, 2022, billed with code 76706-26.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing provided on October 21, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was not 
billed with the appropriate DEX Z-code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the claim was not billed with the appropriate DEX Z-code. 
However, the submitted claim form shows that DEX Z-code ZBBLD was billed. Without supporting 
documentation from the Plan showing that this code is incorrect and what the correct code should but, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the testing provided on 
October 21, 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: 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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the LTACH services requested do not meet 
the requirements for approval. 
 
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 that there are no services at the LTACH that the patient requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.