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

 
We decided that the Plan does not have to pay for outpatient hospital services provided on May 2, 2022. 
 
You asked the Plan to pay for outpatient services. You say that this claim was billed correctly, and these 
services are supported in the records. The Plan denied your request. The Plan says this claim has an Integrated 
Outpatient Code Editor (I/OCE) edit error, and this claim cannot be paid until this information is corrected. 
 
The Plan must follow Medicare rules. Medicare rules say that code G0463 has a Status Indicator of V, which 
means that this code is an Evaluation and Management (E&M) code used to report a medical visit that takes 
place on the same date that a procedure with status indicator S or T is performed, but that is significant and 
separately identifiable from the procedure. The rules say that when and E&M code is on the same day as a type 
T or S procedure does not have a modifier of 25, then edit 21 applies and the claim is returned to the 
provider for correction. 
 
We reviewed the I/OCE Specifications file for this date of service. OCE edit 21 is invoked when One or more 
type T or S procedures occur on the same day as a line item containing an E&M code without modifier 25. 
G0463 is an E&M code which, in this case, was billed with 71046, which has a status indicator of S. Modifier 
25 was not billed with this service. Therefore, edit 21 applies and this claim is rejected to be returned to the 
provider for correction. Based on this information, we decided that Medicare rules for coverage of outpatient 
services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital 
services provided on May 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy services at a tertiary care center. 
 
You asked the Plan to pre-approve therapy services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that speech therapy services are not medically necessary at a tertiary 
care center and can be provided in a community level setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 therapy services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the requested services exceed your medical need as the speech 
therapy sessions can safely and effectively be provided at a lower level of care than a tertiary care center. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve speech therapy services at a tertiary care center.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric walker. 
 
You asked the Plan to pre-approve a bariatric walker. You say that you do not feel safe in the standard sized 
walker and you are afraid you are going to fall. The Plan denied your request. The Plan says you do not meet 
criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty walker is covered for enrollees who 
meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. Review of the file shows that you do not weigh more than 300 
pounds. Based on this information, we decided that Medicare rules for coverage of a bariatric walker have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a bariatric walker.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the request does not meet medical standards for coverage. The Plan says that the 
enrollee does not need or require a physician with specialized rehabilitation training or a coordinated 
interdisciplinary team. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a past medical history of stroke in 2017 and is living at home with weakness and frequent falls. The 
enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve spinal cord stimulator (SCS) implantation. 
 You asked the Plan to pre-approve SCS implantation. The Plan denied your request. The Plan says that this is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is covered for the indications 
established in the applicable LCD/NCD. 
 
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 SCS implantation. Our reviewer says 
that the requested SCS implantation is medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has failed multiple conservative therapies and is not a surgical candidate. The enrollee meets 
the coverage criteria, and the procedure is medically reasonable and 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 SCS implantation have been met. Therefore, we decided that the Plan has to 
pre-approve spinal cord stimulator (SCS) implantation.  
 
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 pay an additional amount for the inpatient hospital services provided 
on April 19, 2021, through June 4, 2021. 
 
You asked the Plan to pay an additional amount for the inpatient hospital services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the services that 
remain denied are considered routine or are not supported by the records. 
 The Plan must follow Medicare rules. Medicare rules say that routine services in a hospital or skilled nursing 
facility generally are those services included in by the provider in a daily service charge--sometimes referred to 
as the "room and board" charge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Specifically, the services and supplies that have 
been denied with code G represent routine services and supplies. No separate payment may be made for these. 
In addition, the remaining services and supplies that have been denied are not supported by the medical 
records. Therefore, we decided that the Plan does not have to pay an additional amount for the inpatient 
hospital services provided on April 19, 2021, through June 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscope provided on January 14, 
2022. 
 
You asked the Plan to waive the copayment for an endoscope. You say that you already paid this copayment, 
and you don't understand why you are 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 $145 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
 You have been asked to pay $127.17, which is less than the original copayment of $145 for an endoscope. This 
item/service falls within the outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 an endoscope provided on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and there was no approved 
authorization. 
 
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 provided on April 12, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve selective internal radiation treatment (SIRT) with yttrium-90 (y-
90). 
 
You asked the Plan to pre-approve SIRT with y-90. You say that you want to complete a y-90 procedure. The 
Plan denied your request. The Plan says that this is not medically reasonable and necessary. 
 
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 SIRT with y-90. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the treatment itself is not investigational. Radioembolization is not outside of the generally 
accepted professional medical standards as being safe and effective. The relevant question is whether or not 
radioembolization is indicated for this enrollee with carcinosarcoma. Liver directed therapy may or may not 
prolong life, and certainly will not cure the condition, but it has a reasonable likelihood of preventing or 
delaying symptomatic progression. This enrollee has had recurrent disease after prior systemic therapy as well 
as liver radiation. Y-90 microspheres/radioembolization is medically necessary for non-colorectal cancer liver 
metastases when other acceptable standard therapies are unlikely to be effective, or when the enrollee's disease 
has progressed on standard therapy. Radioembolization would be appropriate and furnished within accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SIRT with y-90 have been met. Therefore, we decided that the Plan has to pre-
approve selective internal radiation treatment (SIRT) with yttrium-90 (y-90).  
 
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 a laboratory service provided on March 16, 2022, by an 
OON provider. 
 
You asked the Plan to pay for a laboratory service. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 a laboratory service provided on March 16, 2022, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face-down positioning equipment you received on dates 
of service December 6, 2021, and December 20, 2021. 
 
You asked the Plan to pay for the face-down positioning equipment. You say that without this equipment, your 
eye would never have healed properly. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that face-down positioning devices are statutorily 
non-covered for all indications. Therefore, we decided that the Plan does not have to pay for the face-down 
positioning equipment you received on dates of service December 6, 2021, and December 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraosseous nerve ablation system. 
 
You asked the Plan to pre-approve Intracept intraosseous nerve ablation system. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested 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 Intracept intraosseous nerve ablation 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a one-month history of worsening low 
back pain. The documentation indicates that the enrollee has failed conservative management of your pain with 
therapy and anti-inflammatory medications. The Intracept procedure is experimental. More research is needed. 
Therefore, the enrollee does not meet criteria for the requested services. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept intraosseous nerve ablation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Intracept intraosseous nerve ablation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the EGD. You say that you need this procedure done and would like to use 
the OON provider. The Plan denied your request. The Plan says the requested provider is an OON provider and 
there are multiple in-network providers that are available and in the enrollee's service area. 
 
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 esophagogastroduodenoscopy (EGD) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasound, elastography (76981), vascular study (93975), and 
abdominal ultrasound (76700) provided on February 1, 2022. 
 
You asked the Plan to pay for the ultrasound elastography, vascular study, and abdominal ultrasound. The Plan 
denied your request. The Plan says that there is a lack of clinical notes showing medical necessity for these 
tests. 
 
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 pay for the ultrasound elastography, vascular study, 
and abdominal ultrasound. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found an ultrasound with elastography and 
duplex doppler vascular imaging are standard of care in the enrollee's setting of chronic hepatitis C under 
treatment. Our reviewer also found that given the enrollee's lab and imaging database that support concern for 
cirrhosis with portal hypertension and thrombocytopenia, the studies under review are appropriate and 
prognostically 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 the ultrasound elastography, vascular study, and abdominal ultrasound have 
been met. Therefore, we decided that the Plan has to pay for the ultrasound, elastography (76981), vascular 
study (93975), and abdominal ultrasound (76700) provided on February 1, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on July 24, 2022. 
 
You asked the Plan to pay for self-administered drugs. The Plan denied your request. The Plan says Medicare 
does not cover self-administered drugs while the member is getting physician, hospital outpatient, or 
ambulatory surgical center services under Medicare Part B prescription drugs. 
 
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 pay for self-administered drugs provided 
on July 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia injections. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Bisphosphonates is required before alternatives like Prolia can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drug or 
any reason it would be unsafe or ineffective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia injections.