Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from June 17, 2022, to June 19, 2022. 
 
You asked the Plan to pay for the inpatient stay. You say that based on the doctor's comments, evaluations, and 
actions, it seems reasonable for you to have been admitted and studied for a unique and unprecedented change 
in your physical and mental well-being. The Plan denied your request. The Plan says that the criteria for 
coverage for inpatient care was not met. 
 The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for the inpatient 
stay provided from June 17, 2022, to June 19, 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 pay for procedure code 99100 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Please note, the Plan has confirmed that you are not 
responsible for payment of these services. Therefore, we decided that the Plan does not have to pay for 
procedure code 99100 billed for date of service August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prophylaxis (D1110). 
 
You asked the Plan to pre-approve prophylaxis. You say that these services are medically necessary. 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 October 31, 2022. 
Therefore, we decided that the Plan does not have to pre-approve prophylaxis (D1110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety 
and efficacy. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) 
and pontics - porcelain/ceramic (D6245) provided on September 13, 2022. 
 
You asked the Plan to pay for the prefabricated post and core in addition to crown and pontics. You say that it 
was not explained to you that this treatment would not be covered. The Plan denied your request. The Plan says 
these services are not covered under your benefits. 
 
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 the prefabricated post and core in addition to crown (D2954) and pontics - porcelain/ceramic (D6245) provided on 
September 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2,000 units of Dysport every three months. 
 
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 Dysport is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not support 
that the requested 2,000 units of Dysport every three months meets the criteria for coverage for this enrollee. 
The appropriate dose of botulinum toxins for upper and lower limb spasticity is 1,500 units. The records do not 
support medical necessity of further units beyond the appropriate dose. 
 
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 2,000 units of Dysport every three months.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on August 29, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 the office visit (99204) provided on August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiogram (CTA) of the neck. 
 
You asked the Plan to pre-approve the CTA. You say that it is medically necessary that the enrollee get the 
CTA done. The Plan denied your request. The Plan says the Medicare criteria was not met; therefore, the CTA 
of the neck is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CTA. Our reviewer says that the 
CTA of the neck is not reasonable and necessary at this time. Our physician reviewer found that in this case the 
enrollee was seen for evaluation by neurology regarding headaches and paresthesia. The enrollee's prior 
imaging studies showed microvascular ischemic changes in the brain but no other significant vascular findings. 
Were there significant concern about carotid stenosis, it would be more appropriate to have the enrollee 
undergo carotid ultrasound. This is a less intense level of service and one that is more commonly and 
customarily used to evaluate for stenosis/occlusion. The enrollee is not otherwise suspected of having an 
aneurysm or acute condition for which imaging would be necessary to direct intervention. The requested 
service (imaging study) would otherwise exceed the enrollee's clinical needs. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography angiogram (CTA) of the neck.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit on October 17, 2021. 
 
You asked the Plan to pay for emergency room visit. You say that you were very sick and didn't know what 
services or medications were giving to you or what you were being billed for. 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 $50 
copayment for Medicare-covered emergency room visits.  
 
 
 
 You have been asked to pay a $50 copayment for emergency room visit. This item/service falls within the For 
Medicare-covered emergency room visits, you pay a copayment of $50. 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 pay for an emergency room visit on October 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard (IVIG) to be provided in an outpatient 
setting. 
 
You asked the Plan to pre-approve Gammagard in an outpatient setting. You say that the requested setting is an 
outpatient infusion center. You say that the enrollee would have to establish with another physician in order to 
receive IVIG in a different setting. You also say that this would be detrimental for care continuity. The Plan 
denied your request. The Plan says it is not medically necessary for the request drug to be provided in an 
outpatient setting. 
 
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 Gammagard in an outpatient setting. 
Our reviewer says that the requested Gammagard to be provided in an outpatient setting is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the provided documentation 
does not support why Gammagard needs to be given in an outpatient setting outside of convenience to to 
enrollee. Therefore, the reviewer found that the requested outpatient setting is not 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 Gammagard in an outpatient setting have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Gammagard (IVIG) to be provided in an outpatient setting.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bevacizumab-awwb (Q5107) to be used in conjunction 
with Carboplatin and Paclitaxel. 
 
You asked the Plan to pre-approve Bevacizumab-awwb. You say that the enrollee is running out of time, and 
needs this procedure done due to medical necessity. The Plan denied your request. The Plan says based on the 
lack of an indication for using Bevacizumab in patients diagnosed with non-small-cell lung cancer, squamous 
cell carcinoma, the off-label denial for Bevacizumab-awwb is upheld under Part C. 
 
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 Bevacizumab-awwb. Our reviewer says 
that Bevacizumab-awwb is not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of non-small cell squamous cell lung cancer. The 
FDA has not stated that the requested drug regimen is indicated for the enrollee's condition. Our reviewer 
found that the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the 
requested drug regimen in the enrollee's clinical situation. No literature from Medicare approved cancer 
journals were submitted for review. Our physician reviewer also found that the elements of the coverage 
criteria are not satisfied, and the requested service cannot be 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 Bevacizumab-awwb have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Bevacizumab-awwb (Q5107) to be used in conjunction with Carboplatin and 
Paclitaxel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amputation services provided on February 15, 2022, to 
February 17, 2022. 
 
You asked the Plan to pay for the amputation services. You say that you disagree with the Plans denial. The 
Plan denied your request. The Plan says this service is an inpatient procedure only. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
 
 The service at issue in this appeal was billed with CPT code 27596. This code is listed with a status indicator of 
C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as 
inpatient only; and therefore, must be billed as part of an inpatient admission. The claim is not payable as 
billed. Therefore, we decided that the Plan does not have to pay for the amputation services provided on 
February 15, 2022, to February 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve therapy services. You say that additional therapy is medically necessary. 
The Plan denied your request. The Plan says the requested services are available 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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 00860. We decided that the Plan does not have to pay for code 
99100.  
 
You asked the Plan to pay for the anesthesia services provided on March 2, 2022.. You say that the coding is 
correct. The Plan says that code 99100 is not separately reimbursable. 
 
We decided that the Plan has to pay for code 00860.  
 
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. 
 
We looked at the file and the rules. The Plan has not made reasonable and diligent efforts to gather and forward 
to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay 
for code 00860.  
 
We also decided that the Plan does not have to pay for code 99100. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for code 99100. 
 
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 procedure code(s) 8341, 88342, 88360, and 88381 billed for 
date of service February 25, 2022. 
 
You asked the Plan to pay for procedure code(s) 8341, 88342, 88360, and 88381. 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 the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 8341, 88342, 88360, 
and 88381. 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) 8341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 8341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 8341, 88342, 88360, and 88381 billed for date of service February 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that enrollee will benefit from acute rehab to optimize 
their level of functioning prior to returning home. You say that the enrollee requires interdisciplinary therapy 
care. You say that the enrollee has a serious life-threatening constellation of acute medical problems that have 
left them at a function status below their baseline. The Plan denied your request. The Plan says an IRF is not 
medically necessary, and the enrollee can get the services they need provided safely in other settings. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.