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

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing. 
 
You asked the Plan to pre-approve TTE testing. You say that you need to reassess the enrollee's left ventricular 
function post-revascularization. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because 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 TTE testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found records reveal that the enrollee was doing well with no chest pain or shortness of breath, no 
orthopnea, edema, or palpitations. Clinical guidelines do not support repeating a TTE test with no intervening 
change in clinical status or physical findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transthoracic echocardiography (TTE) testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted procedure of the abdomen, peritoneum and 
omentum (49999) provided on November 23, 2021. 
 
You asked the Plan to pay for the unlisted procedure of the abdomen, peritoneum and omentum (49999). You 
say that there is no specific CPT code for this procedure, so the unlisted code is used. You say that the 
operative note documents the procedure as performed and the claim should be sent back for review. The Plan 
denied your request. The Plan says procedure codes 38747 and 48150 were approved. The Plan also says that 
procedure code 49999 is not supported in the medical records. 
 
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 49999 is unlisted procedure, abdomen, peritoneum and 
omentum. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the unlisted procedure of the abdomen, peritoneum and 
omentum (49999). Our reviewer says that the documentation submitted was reviewed and does not meet the 
criteria for coverage. Our reviewer found that no CPT code exists for this procedure. The documentation states 
a procedure was performed; however, no description of the actual procedure was documented. Therefore, this 
procedure cannot be confirmed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the unlisted procedure of the abdomen, peritoneum and omentum (49999) have 
not been met. Therefore, we decided that the Plan does not have to pay for the unlisted procedure of the 
abdomen, peritoneum and omentum (49999) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 11 extractions provided on January 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you carefully planned everything out. You say 
that a predetermination was requested. You say that it took a very long time to receive the predetermination 
decision. You also say that you feel that the plan dropped the ball. The Plan denied your request. The Plan says 
the claim processed correctly. 
 
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 and extractions are listed as covered, 
the frequency limit has been exceeded. The record shows that the Plan paid for the extractions for teeth # 1 and 
16. Therefore, we decided that the Plan does not have to pay for the 11 extractions provided on January 6, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you do not have any transportation for 
dialysis three times a week. The Plan denied your request. The Plan says the established benefit was exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. The Plan denied your request. The Plan says this 
appeal for Ondansetron does not meet Medicare criteria for coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablets.  
 
Benefits for Ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial preventive physical examination; face-to-face visit, 
services limited to new beneficiary during the first 12 months of Medicare enrollment (CPT code G0402) and 
hospital outpatient clinic visit for assessment and management of a patient (CPT code G0463) provided on 
October 15, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The provider did not bill as required by Medicare coding regulations. Multiple medical visits on the same day 
were reported with the same revenue center on HCPCS codes G0402 and G0463 and condition code G0 was 
not reported. Therefore, we find the Medicare rule for payment of this October 15, 2021, claim has not been 
met and could not be processed for payment. 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 pay for initial 
preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 
months of Medicare enrollment (CPT code G0402) and hospital outpatient clinic visit for assessment and 
management of a patient (CPT code G0463) provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services (CPT code 99496) 
provided on July 15, 2021.  
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. The Plan states per the 
Medicare guidelines, the claim did not meet TCM billing requirements, and the claim is not eligible for 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Review of the file shows that the provider billed CPT 99496 for the date of service, July 15, 2021. However, 
the enrollee was discharged from the hospital on the same day. Per the guidelines, the required face-to-face 
visit can't take place on the same you report discharge day management services. Additionally, another 
provider has billed CPT 99495 for date, June 30, 2021, which was paid by the plan on August 24, 2021. This 
code was billed within the seven (7) calendar days of discharge from the hospital. Per the guidelines, the 30-
day TCM period begins on a patient's inpatient discharge date and continues for the next twenty-nine (29) days 
and only one (1) physician or NPP may report TCM services. 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 pay for transitional care management services (CPT code 99496) provided on July 15, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the patient would have much difficulty tolerating 3 hours of therapy a 
day. 
 
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. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no rehab nursing needs identified or documented in the record. At the current 
functional level, the enrollee needs lower intensity rehab. The enrollee does not need IRF level of therapies, 
and her rehab needs can be met in lower setting. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal photopheresis (36522) provided December 1, 
2021. 
 
You asked the Plan to pay for extracorporeal photopheresis. You say that the continuity of care for apheresis is 
in the best interest of the enrollee and supported by the letter of medical necessity from the physician. The Plan 
denied your request. The Plan says the service is not deemed 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 pay for extracorporeal photopheresis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewed documentation indicates that the enrollee has at least a three-year 
history and treatment for Castlemans disease, a disorder which leads to proliferation of cells in the lymphatic 
system. She developed dyspnea and airway obstruction consistent with Bronchiolitis Obliterans. She has failed 
inhalers. Cytoxan treatment, and oral cyclosporine. Scans have shown disease progression. She has been on 
apheresis treatment since 2018 which has resulted in ending supplemental oxygen and hospitalizations. Per the 
coverage criteria, Medicare covers extracorporeal photopheresis for bronchiolitis obliterans syndrome (BOS) 
following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical 
research study. The review has determined that the medical records provided do not meet the requirements 
listed in the NCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracorporeal photopheresis have not been met. Therefore, we decided that the 
Plan does not have to pay for extracorporeal photopheresis (36522) provided December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myopro Powered Arm Brace (CPT code L8702). 
 
You asked the Plan to pre-approve the brace. You say that this is to help the enrollee recover from disability in 
the right upper extremity. The Plan denied your request. The Plan says experimental and investigational 
procedures are not covered by Medicare. 
 
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 brace. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of 
the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myopro Powered Arm Brace (CPT code L8702).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a non-obstetric ultrasound of the pelvis 
(76857) performed by an in-network provider on January 5, 2022. 
 
You asked the Plan to waive the copayment for a pelvic ultrasound. You say that your payment should be zero 
but you have been asked to pay almost 50% of the bill. You say that you should not have to pay this amount for 
Advanced Imaging Services. The Plan denied your request. The Plan says the copayment was applied correctly 
according to your contract. Furthermore, the Plan says that in order for Advanced Imaging Services to have a 
$0 copayment, you must receive the services at an Independent Diagnostic Testing Facility (IDTF). 
 
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 $75 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  Your contract also says that the $75 copayment applies to diagnostic procedures (including ultrasounds) 
provided at all locations of service EXCEPT Independent Clinical Laboratories (ICLs), outpatient hospital 
facilities, Independent Diagnostic Testing Facilities (IDTFs), or physicians offices.   
 
You have been asked to pay a $75 copayment for a pelvic ultrasound. The service at issue falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Moreover, the services 
you received were not provided at a location with a copayment exception. 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 copayment for a non-obstetric ultrasound of the pelvis (76857) provided on January 5, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has not trialed one viscosupplemental treatment such as Orthovisc or Supartz FX. Step therapy, as 
outlined by the Plan, requires that one of these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Synvisc (J7325).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient services provided from September 
30, 2021, to October 5, 2021. 
 
You asked the Plan to waive the copayment for inpatient services. You say that you were told services would 
be covered since its COVID-19 related. The Plan denied your request. The Plan says the copayment applied 
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 $250 
copayment per day for days 1-7 for inpatient services.  
 
 
 
 You have been asked to pay a $1,250 copayment for the inpatient services ($250/day x 5 days = $1,250). The 
inpatient services fall within the Inpatient hospital care 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 copayment for inpatient services provided from September 30, 2021, to October 5, 2021.
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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 that you were admitted for mitral valve replacement. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. In conclusion, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Diltiazem capsule. 
 
You asked the Plan to pre-approve Diltiazem. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Diltiazem 
capsule.  
 Benefits for Diltiazem may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.