Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that this is supported as an appropriate 
intervention. The Plan denied your request. The Plan says this device has special custom fabricated features 
that should not be covered. 
 
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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current clinical guidelines designate robotic therapy to be of uncertain utility 
compared with dose-matched conventional upper limb exercise therapies with unproven benefit in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G orthotic device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on June 08, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. 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 $250 
copayment for each one-way Medicare-covered air trip ambulance service. Covered ambulance services 
include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can 
provide care only if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health or if authorized by the plan. 
 
You have been asked to pay a $250 copayment for ambulance. This item/service falls within the Ambulance 
services 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 ambulance on June 08, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Opdivo and Yervoy. 
 
You asked the Plan to pre-approve Opdivo and Yervoy. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this regimen is not medically 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 Opdivo and Yervoy. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested regimen. Our physician reviewer found 
the Food & Drug Administration has not stated that the requested drug combination is indicated for the 
enrollee's condition. These drugs are not supported by one of the major drug compendia or by clinical research 
appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo and Yervoy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of Opdivo and Yervoy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Paroxetine. 
 
You asked the Plan to pre-approve Paroxetine. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Paroxetine.  
 
Benefits for Paroxetine 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 an office visit, laboratory services, and diagnostic/screening 
processes provided on August 24, 2022, by an OON provider. 
 
You asked the Plan to pay for an office visit, laboratory services, and diagnostic/screening processes. You say 
that you are appealing with supporting records. The Plan denied your request. The Plan says the enrollee must 
receive care from a network provider. 
 
 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 an office visit, laboratory services, and 
diagnostic/screening processes provided on August 24, 2022, by an OON provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 provided on July 26, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
  
We find that CPT code 76641 was billed with 1 unit of service with modifier RT on one claim line, and 1 unit 
of service and modifier LT on the second claim line. We also find that code 76641 has an MUE of 2, not 1. 
Based on this information, we decided that Medicare rules for coverage of the billed services have been met. 
Therefore, we decided that the Plan has to pay for procedure code 76641 provided on July 26, 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 an in-network exception for an office visit and treatment 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an in-network exception for an office visit and treatment to be provided by 
an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there 
are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
an in-network exception for an office visit and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364) provided by a participating 
provider on July 19, 2022. 
 
You asked the Plan to pay for a cone beam CT capture. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the denied services are not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam CT capture (D0364) provided by a participating provider on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95861, 95868, 95927, and 95938 billed for 
date of service December 16, 2021. 
 
You asked the Plan to pay for procedure code(s) 95861, 95868, 95927, and 95938. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95861, 95868, 95927, 
and 95938. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 95861, 
95868, 95927, and 95938. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 95861, 95868, 95927, and 95938 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code(s) 95861, 95868, 95927, and 95938 billed for date of service December 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says admission to an LTACH 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78830 billed for date of service July 14, 
2022. 
  You asked the Plan to pay for procedure code 78830. You say that the attached records support multiple 
procedures rendered on this date. You say that the charges should be reprocessed for separate reimbursement. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 78830 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 78830 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 78830 billed for date of service July 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio (J1306). 
 
You asked the Plan to pre-approve Leqvio. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Praluent. 
 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 Leqvio. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found he provided records do not indicate that the 
enrollee has tried and failed the plan's preferred drug. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred drug. Therefore, the reviewer 
found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio (J1306).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says that the criteria for admission to SNF have not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that patient still has complex functional neurological 
deficits/impairments. Clinical documentation shows that patient continues to require skilled nursing assessment 
for pain management and daily skilled services in a skilled nursing facility is 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an all-white glass crown (D2740) for tooth number 14 provided on 
August 18, 2022. 
 
You asked the Plan to pay for an all-white glass crown (D2740) for tooth number 14. You say that your dentist 
fixed your cavity and applied a crown over it. You also say that you feel great and are able to eat with it. The 
Plan denied your request. The Plan says that the all-white glass crown (D2740) for tooth number 14 is not 
medically necessary. 
 
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. The Plan covers all white glass 
crown (D2740) for tooth number 14 when the services are medically necessary and reasonable. 
 
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 all white glass crown (D2740) for tooth 
number 14. Our reviewer says that as the tooth was repairable, the treatment was reasonable and medically 
necessary. Our physician reviewer found due to the extensive loss of structure (around 50%), a crown along 
with a core buildup for replacing the distal wall and distal cusp would be appropriate. Our physician reviewer 
also found that the x-rays, along with the notes from the provider, do show the distal decay is above the level of 
the bone. Our physician reviewer also found there is minimal structure available on the distal, but the provider 
stated the margin was accessible. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of all white glass crown (D2740) for tooth number 14 have been met. Therefore, 
we decided that the Plan has to pay for an all-white glass crown (D2740) for tooth number 14 provided on 
August 18, 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: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75716. We decided that the Plan does not have to pay for 99153.  
 You asked the Plan to pay for angiography and moderate sedation services provided to the enrollee on June 14, 
2022.. You say that this should be paid for. The Plan says that there is insufficient documentation in the 
operative report to approve the modifier requested. 
 
We decided that the Plan has to pay for 75716.  
 
The Plan follows Medicare rules. Medicare rules say that modifier -59 is used to indicate a distinct procedural 
service.  
 
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 for CPT 75716. The definition of this code is 
"Angiography, extremity, bilateral, radiological supervision and interpretation."   
 
Our reviewer says that this codes for interpretation and supervision of bilateral extremity angiography.  There 
is satisfactory documentation that this work has been performed with a detailed report in the medical record of 
the findings of the bilateral lower extremity angiogram. As there is no evidence that there was a prior study, 
this diagnostic angiography is separately reportable and not bundled with the iliac stent procedure code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
75716.  
 
We also decided that the Plan does not have to pay for 99153. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting. 
 
The definition of CPT 99153 is "Moderate sedation services provided by the same physician or other qualified 
health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring 
the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition 
to code for primary service)." 
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 99153 have not been met. Therefore, we decided that the Plan does not have to pay for 99153. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (97026) provided on May 16, 2022. 
 
You asked the Plan to pay for infrared therapy (97026). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says infrared therapy is considered not reasonable and 
necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for infrared therapy (97026) provided on May 16, 2022.