Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve allergy testing. 
 
You asked the Plan to pre-approve the requested services. You say that the process allows the enrollee to speed 
up the process of controlling his allergies. The Plan denied your request. The Plan says that allergen 
immunotherapy should be differentiated from the process of desensitization. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 requested services. Our physician 
reviewer found that the enrollee has a history of allergic rhinitis due to pollen, animal dander who reported 
itchiness in skin on back and testicles after not having lasting benefit with steroid creams and pills. No rash was 
noted on examination. SPT showed positive reaction to grasses, weeds, trees, dust mites, and mold. Allergen 
immunotherapy (AIT), subcutaneous immunotherapy (SCIT) was requested. Immunotherapy (SCIT or SLIT) is 
recommended and appropriate in this situation where the patient has failed oral medications and topical 
formulas. Standard of care guidelines support use of this treatment in this clinical situation. Reducing the 
sensitivity to his allergies is likely to improve his itchiness. SCIT is reasonable and medically necessary for this 
patient's condition. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve allergy testing.  
 
 
 
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided from 
October 17, 2021, to October 19, 2021. 
 
You asked the Plan to waive the copayments for an inpatient hospital stay. You say that you cannot afford the 
copayments due to little income. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $350 
copayment per day for days 1-5 of inpatient hospital care. There is no charge after day 5. You have been asked to pay a total of $700, which is a $350 copayment per day for an inpatient hospital stay 
($350 copayment x 2 days = $700). There is no charge for the day of discharge. An inpatient hospital stay falls 
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 copayments for 
an inpatient hospital stay provided from October 17, 2021, to October 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided by an out-of-network 
provider from January 28, 2021, through February 1, 2021. 
 
  You asked the Plan to pay for the inpatient hospital services. You say that the patient was admitted with 
straight Medicare primary insurance and no secondary insurance on file. You say that the psychiatrist felt it 
was clinically appropriate to admit and you are requesting authorization. The Plan denied your request. The 
Plan says prior authorization was not obtained. 
 
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 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 the inpatient hospital services provided by an out-
of-network provider from January 28, 2021, through February 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care (99291), provided on September 12, 2021. 
 
You asked the Plan to pay for the critical care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the member was enrolled in hospice on the date of this service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the critical care (99291), provided on September 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has mild cognitive 
impairment and is not on any medication for Alzheimer's disease. Her last mini-mental status exam (MMSE) 
was 29 out of 30, which correlates with normal cognition. Magnetic resonance imaging (MRI) of the brain 
showed extensive white matter disease and left parietal hemosiderin. The documentation does not support that 
Aduhelm is medically reasonable and necessary for the enrollee in this case. The MMSE score correlates with 
normal cognition. The MRI suggests a mixed etiology for the enrollee's symptoms. There is no documented 
trial and failure of an appropriate medication. It has not been shown that Aduhelm (Aducanumab) is at least as 
beneficial as existing and appropriate and available medically appropriate alternatives for this enrollee. The 
documentation does not support that Aduhelm is reasonably expected to be safe and effective for this enrollee. 
 
 
 
  
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 Aduhelm.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction (D3331) for teeth # 3 
and 6. 
 
You asked the Plan to pre-approve the dental services. You say that you are not able to drink hot or cold 
beverages. You say that it hurts every time you chew. You also say that you cannot afford to pay for the root 
canal treatments because you are low income. The Plan denied your request. The Plan says treatment of root 
canal obstruction is not listed as covered. 
 
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 root canal treatments are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
treatment of root canal obstruction (D3331) for teeth # 3 and 6.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. You say that there is no ability to collect tissue biopsy. The Plan 
denied your request. The Plan says the enrollee has an unknown PD-L1 status. 
 
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 Keytruda. Our physician reviewer 
found that the enrollee has presumed stage III non-small cell lung cancer. Molecular testing was negative, but 
there was no tissue diagnosis or PDL1 results. The requested use of Keytruda is not FDA approved without a 
tissue diagnosis or PDL1 testing. The requested use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. The documentation does not support that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab (Keytruda).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane injections. 
 
You asked the Plan to pre-approve Durolane. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the limitations specified in the coverage criteria have 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat hyaluronan injections for shoulder arthritis 
are limited to a single repeat course. 
 
We looked at the file and Medicare rules. In this case, repeat injection services have already been performed. 
Additional injections for shoulder arthritis will not be approved. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane injections.
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 therapy is needed before you return home after a 
recent hip replacement. The Plan denied your request. The Plan says you can be managed at a lower level of 
care. 
 
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 are medically stable and do not need physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. 
At the current functional level, you do not need intensive therapies, consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. IRF admission is not 
medically necessary based on lack of medical complexity and lack of acute rehab nursing needs. Your rehab 
needs can be met at a lower intensity setting. 
 
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 substance use residential treatment to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve substance use residential treatment. You say that this is the only facility that 
has a space for you. The Plan denied your request. The Plan says there is an in-network facility that can provide 
these services. 
 
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 substance use residential treatment to be 
provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is 
considered experimental in nature, as more research is needed to support efficacy. The services are therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have a 
diagnosis of T3b prostate cancer. There is insufficient prospective, long-term clinical data available to 
determine whether or not proton beam radiation therapy for prostate cancer is superior to external beam 
radiation therapy, intensity modulated radiation therapy (IMRT), or brachytherapy in regards to safety and 
effectiveness. The most recent American Urological Association guidelines state that proton beam therapy 
offers no clinical advantage over other forms of definitive treatment. The services are therefore not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head and neck 
(70450) provided on September 25, 2021. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations.  
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 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) scan of the head and neck 
(70450) provided on September 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 13, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 83789-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that specimen validity testing is not covered 
separately.  
 
The services at issue in this case are for the purpose of specimen validity testing. 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 laboratory services provided to the enrollee on April 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the telehealth visits provided on November 23, 2020, and December 1, 
2020. 
 
You asked the Plan to pay for the telehealth visits. You say that the medical records demonstrate the medical 
necessity, and the denial should be reconsidered. The Plan denied your request. The Plan says that modifier GT 
is invalid with Place of Service (POS) 11. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says the POS is invalid with the modifier billed. The Plan did not 
submit the claim form to support that POS 11 was billed. Therefore, we decided that the Plan has to pay for the 
telehealth visits provided on November 23, 2020, and December 1, 2020.  
 
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 a spinal cord electric stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in a lot of pain. The Plan 
denied your request. The Plan says the trial occurred over 14 months ago. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators for chronic pain are only 
covered under certain medical indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. She has tried a home exercise program, a back 
brace, non-steroidal anti-inflammatory drugs, and prior lumbar spine injections. She had a prior spinal cord 
stimulator (SCS) trial. She has not had a formal psychological evaluation. She has not had prior surgery and 
does not have an evidence-based indication for an SCS. Therefore, the requested service is not medically 
reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord electric stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were billed correctly and should be 
paid. The Plan denied your request. The Plan says you billed an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for lab services provided on June 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam (88305) provided on August 12, 2021. 
 
You asked the Plan to pay for the tissue exam. You say that you would like this claim reprocessed based on the 
medical documentation. The Plan denied your request. The Plan says the provider has not billed this claim as 
required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 88305 is not supported in the record. Specifically, the record indicates that the member 
was in an outpatient facility on the billed date of service. The record also shows that CPT code 88305 was 
billed by the facility on the same date of service. Payment for the technical component of this service is 
included in the payment to the facility and is the responsibility of the facility to any vendor. Based on this 
information, we decided that Medicare rules for coverage of the tissue exam have not been met. Therefore, we 
decided that the Plan does not have to pay for the tissue exam (88305) provided on August 12, 2021.