Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the enrollee has multiple myeloma and radiation 
therapy is requested to treat the pelvis. 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 to the complex 
isodose treatment that they can approve. 
 
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 IGRT. Our reviewer says that IGRT is 
not considered medically reasonable and necessary in this case. Our physician reviewer found IGRT is a means 
to improve set-up accuracy. IGRT uses daily image guidance to help localize the target to minimize normal 
tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to 
radiation. For radiation in the palliative setting, IGRT could be considered medically necessary when it is 
necessary to escalate the dose (i.e., oligometastases), particularly when using very high dose per fraction, or 
when critical normal tissues abutting the target necessitate daily image guidance to allow minimal planning 
margins to spare the normal tissue.  In this case, the intent is clearly palliative, and it is not clear what benefit 
IGRT would afford. The records do not provide a plausible rationale for the need for IGRT. It appears IGRT is 
being used as routine practice, as there does not seem to be any exceptional circumstances with this enrollee, 
necessitating the need for IGRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve neurosurgery consultation with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON neurosurgery consultation. You say that the network providers 
offered by the Plan all have office around an hour away, but you state that if you require surgery, you would 
need to travel two hours for that service. You indicate that the OON provider has an office very close by, and 
for surgery, you would only need to travel approximately one hour to Green Bay. The Plan denied your request. 
The Plan says that the service requested is an outpatient office visit, which is available in-network at a 
reasonable time/distance. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The requested neurosurgeon is a non-contract provider. We were able to confirm that the Plan does not have 
contract providers located within reasonable distance and travel time from your home who can provide the 
required services. Though the network surgeons may have offices which are within a reasonable distance, if 
surgery is deemed necessary, the location at which the surgery is provided is more than two hours from your 
home. This is not a reasonable time/distance for surgical services in your county according to Medicare 
guidelines. Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we 
decided that the Plan has to pre-approve neurosurgery consultation with an out-of-network (OON) provider.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspiration (20939) for a spinal surgery. 
 
You asked the Plan to pre-approve a bone marrow aspiration. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 a bone marrow aspiration. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that bone marrow aspirate use is 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 a bone marrow aspiration have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone marrow aspiration (20939) for a spinal surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Degarelix (CPT code J9155). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found although Degarelex is FDA and compendia approved for metastatic prostate cancer, if Eligard was 
already given, it would be duplicative. Our physician reviewer states that they would have approved Degarelix 
240MG x 1 if Eligard was given one (1) month later. Otherwise, this is being denied for duplication. 
 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Degarelix (CPT code J9155).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for an upper partial denture (D5225) 
provided on June 7, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you want the Plan to pay 
an additional amount. The Plan denied your request. The Plan says you had already utilized $506.37 of the 
calendar year and had $496.63 remaining available from your benefit limit to pay towards the remaining 
balance. You are responsible for $949.37. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 7, 2022. Therefore, 
we decided that the Plan does not have to pay an additional amount for an upper partial denture (D5225) 
provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy - molar 
(D3348). 
 
You asked the Plan to pre-approve dental services. You say that you need to have this service approved. The 
Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Retreatment of previous root 
canal therapy - molar (D3348) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested retreatment of previous 
root canal therapy - molar (D3348) is not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve retreatment of previous root canal therapy - molar (D3348).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 37186 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 37186. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 37186 is bundled into 
payment for code 37233. 
 
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 37186 
is a column II code to column I code 37233. 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 37186 billed for date of service April 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 were admitted for gastrointestinal bleeding, cardiac arrest and respiratory failure. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for pain and swelling of the legs. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740). 
 
You asked the Plan to pre-approve a porcelain/ceramic crown. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 26, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker holder (K0108). 
 
You asked the Plan to pre-approve a walker holder. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a walker holder (K0108).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services (A0428, A0425) 
provided on January 20, 2022. 
 
You asked the Plan to pay for non-emergency ambulance services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says transportation other than an ambulance (e.g., private 
car, wheelchair van, etc.) could be utilized without endangering the individual's health. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
   
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 non-emergency ambulance services. Our 
reviewer says that the services were not medically necessary. Our physician reviewer found the record does not 
indicate that the enrollee's clinical condition is such that other methods of transport, such as stretcher van, are 
contraindicated or that the expertise, services and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance can provide was required. The record provided does not establish the medical necessity 
and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for non-emergency ambulance services (A0428, A0425) provided on January 
20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the chemotherapy provided on May 19, 2022 to 
May 20, 2022. 
 
You asked the Plan to waive the cost for chemotherapy. You say that your medical health plan sent you a bill 
with erroneous charges. 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 20% 
coinsurance for drugs that usually aren't self-administered by the patient and are injected or infused while you 
are getting physician, hospital outpatient, or ambulatory surgical center services.  
 
You have been asked to pay $988.21, which is 20% of the allowed amount for the chemotherapy. The allowed 
amount is $4941.04 (20% x 4941.04 = $988.21). The chemotherapy service falls within the Medicare Part B 
Prescription Drugs 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 cost for the chemotherapy provided 
on May 19, 2022 to May 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for arthrocentesis and foot inserts provided on May 4, 
2022. 
 
You asked the Plan to waive the cost for arthrocentesis and foot inserts. 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 $40 
copayment for out-of-network Medicare-covered specialist services and a 35% coinsurance for each out-of-
network Medicare-covered durable medical equipment item. 
 
 You have been asked to pay a total of $240.52 for the office visit and foot inserts. The Plan reprocessed the 
cost share for the foot inserts from a 50% out-of-network care to a 35% out-of-network share. You are 
responsible for the $40 copayment for the out-of-network specialist visit. 
 
PROCEDURE 
CODE 
AMOUNT 
BILLED 
ENROLLEE 
COPAYMENT 
ENROLLEE 
COINSURANCE 
PLAN 
PAYMENT 
ENROLLEE 
RESPONSIBILITY 
20605 $120.00 $40.00 $0.00 $19.40 $40.00 
L3000 $350.00 $0.00 $100.26 $228.85 $100.26 
L3000 $350.00 $0.00 $100.26 $228.85 $100.26 
TOTAL     $240.52 
 
The office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits, and the foot 
inserts fall within the Durable Medical Equipment (DME) and related supplies benefit categories. 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 cost for arthrocentesis and foot inserts provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided February 24, 2022.

You asked the Plan to pay for the genetic testing. You say that you believe that the biomarker testing services should be a covered Plan benefit because testing was ordered by the in-network physician and the in-network physician determined the results of these services medically necessary. The Plan denied your request. The Plan says this service does not meet Medicare criteria.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The MI profile by CARIS is not listed as a Medicare covered service on DEX Diagnostics by Palmetto GBA. In addition, per CMS guidelines, NCD 90.2 criteria is not met for the requested test as the enrollee did not have recurrent, relapsed, refractory, metastatic or advanced stage III or IV cancer. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided February 24, 2022.