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

 
We decided that the Plan does not have to reduce the copayment for the discontinued biopsy provided on 
August 25, 2022. 
 
You asked the Plan to reduce the copayment for the discontinued biopsy. You say that you think that the cost 
sharing for this service should be lower. 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 a visit to an outpatient hospital facility. 
 
You have been asked to pay a $162.50 copayment for the discontinued biopsy because the Plan is only holding 
you responsible for this amount, which is less than the $250 copayment. This item/service falls within the 
outpatient surgery, including 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 reduce the copayment for the discontinued biopsy 
provided on August 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the spinal canal and contents, cervical; without contrast material (CPT 72141).

You asked the Plan to pre-approve an MRI of the spinal canal and contents, cervical; without contrast material (CPT 72141). You say that the requested MRI is medically necessary. The Plan denied your request. The Plan says the requested MRI does not meet the Medicare NCD coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the spinal canal and contents, cervical; without contrast material. Our reviewer says that an MRI of the spinal canal and contents, cervical; without contrast material is not medically necessary in this case. Our physician reviewer found no detailed neurological exam in the records. No plain film x-ray report has been submitted. The medical necessity of the requested MRI cervical spine has not been demonstrated in the submitted records.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the spinal canal and contents, cervical; without contrast material (CPT 72141) have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the spinal canal and contents, cervical; without contrast material (CPT 72141).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy performed on 
November 7, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you do not agree with the cost 
sharing applied to this service. 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 $90 
copayment for Medicare-covered surgery services provided in an outpatient hospital. 
 
 You have been asked to pay a $90 copayment for the colonoscopy. This item/service falls within the outpatient 
surgery, including 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 the diagnostic colonoscopy performed on 
November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint injection. 
 
You asked the Plan to pre-approve a lumbar facet joint injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that it is not considered medically reasonable and 
necessary to perform multiple blocks (ESIs, sympathetic blocks, facet blocks, trigger point injections, etc.) 
during the same session as ESIs, with the exception of a facet synovial cyst and ESI performed in the same 
session. 
 
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 a lumbar facet joint injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found only one procedure 
per day will be covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar facet joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar facet joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MAKOplasty robotic assistance to be provided 
during an approved knee surgery. 
 
You asked the Plan to pre-approve the MAKOplasty assistance. You say that it is felt that this surgery is 
needed as requested. The Plan denied your request. The Plan says the use of this robotic assistance is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MAKOplasty assistance. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are no large volume, long-term/high-quality clinical studies that 
confirm clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. The provided documentation does 
not corroborate any significant limb abnormalities or evidence on imaging that would preclude the use of 
standard surgical approaches for a successful procedure. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested MAKOplasty robotic assistance for knee surgery, in this case, 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 MAKOplasty assistance have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MAKOplasty robotic assistance to be provided during an approved knee 
surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for four EpiFix allografts provided from April 
5, 2022, to April 28, 2022. 
 
You asked the Plan to waive the coinsurance for a skin graft. You say that you were never told what this would 
cost you. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a $527.81 coinsurance for four skin grafts ($2,639.07 allowed amount x 20% 
coinsurance = $527.81 for each date of service). You have been asked to pay a total of $2,111.24 ($527.81 x 4 
dates of service = $2111.24 coinsurance). This item/service falls within the Medicare Part B prescription drugs 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 coinsurance for four EpiFix allografts provided 
from April 5, 2022, to April 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 72131 and two units of 
procedure code 72128 both provided on September 11, 2022. 
 
You asked the Plan to pay for the codes as billed. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the claim was billed with 2 units for codes 72131 and 72128, 
documentation does not support that the imaging was read or done twice on this date of service.  

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The records do not show that this imaging was provided twice. Based 
on this information, we decided that there is insufficient information in the record to determine if Medicare 
rules for coverage of the CT scan of lower spine and spondylosis allied disorders have been met.  Therefore, we 
decided that the Plan does not have to pay for two units of procedure code 72131 and two units of procedure 
code 72128 both provided on September 11, 2022.
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 the enrollee is septic and needs rehabilitation. The 
Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be 
met at a lower level of care such as a skilled nursing facility. 
 
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 enrollee was admitted for osteomyelitis and had a below the knee amputation. The enrollee's medical problems are stable, and 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. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 enrollee has a past medical history of hypertension, depression and dysphagia and is living at home with weakness, weight loss, and functional debility. The enrollee's medical problems are 
stable, and 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. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 1 fraction of Low-Energy X-Ray intraoperative radiation therapy  
(IORT), delivered as a single fraction at the time of lumpectomy (CPT code 77424). 
 
You asked the Plan to pre-approve 1 fraction of Low-Energy X-Ray intraoperative radiation therapy - IORT, 
delivered as a single fraction at the time of lumpectomy. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the requested services are not medically 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 1 fraction of Low-Energy X-Ray 
intraoperative radiation therapy - IORT, delivered as a single fraction at the time of lumpectomy. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee a diagnosis of invasive ductal carcinoma of the left breast, T1aN0M0. 
The radiation oncologist writes that this treatment recommendation is consistent with NCCN guidelines. The 
requested services are considered medically necessary for enrollees with early breast cancer, as this enrollee 
has, risk adapted immediate single dose intraoperative radiation therapy (IORT) during lumpectomy has been 
shown to be an effective alternative to EBRT, with comparable long-term efficacy for cancer control and lower 
non-breast cancer mortality. Evidence from meta-analyses with good statistical precision supports the 
effectiveness of IORT. Three evidence-based guidelines from American and European oncology societies 
consider IORT to be safe and effective. Therefore, the enrollee does 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 1 fraction of Low-Energy X-Ray intraoperative radiation therapy - IORT, 
delivered as a single fraction at the time of lumpectomy have been met. Therefore, we decided that the Plan has 
to pre-approve 1 fraction of Low-Energy X-Ray intraoperative radiation therapy  (IORT), delivered as a 
single fraction at the time of lumpectomy (CPT code 77424).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve the full set of upper and lower dentures (D5110, 
D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to eat and have very high 
blood pressure due to the stress of this situation. 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 June 19, 2019. Therefore, 
we decided that the Plan does not have to pre-approve the full set of upper and lower dentures (D5110, D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new set of dentures. 
 
You asked the Plan to pre-approve the dental services. You say that you have money on your account. You also 
say that you think it should be paid for because it was a lost item. 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 December 13, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a new set of dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation - established patient (D0120). 
 
You asked the Plan to pre-approve the dental services. You say that you have medical issues that would need to 
keep you closer to home for your medical appointments. The Plan denied your request. The Plan says dental 
services from an out-of-network provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a periodic 
oral evaluation - established patient (D0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery radiation therapy. 
 
You asked the Plan to pre-approve proton treatment delivery. 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 proton treatment delivery. 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 cT1CN0M0, Gleason's grade 4+4 adenocarcinoma of the prostate. 
Baseline Prostate Specific Antigen (PSA) level is 20.2 ng/mL. A magnetic resonance imaging scan of the 
enrollee's prostate gland showed a three-centimeter left lobe nodule without extra-prostatic extension. A 
Positron Emission Tomography (PET) scan on January 12th, 2023, was negative for metastatic disease. There 
is insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation 
therapy for prostate cancer is superior, inferior, or equivalent to external beam radiation therapy, intensity-
modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
 Recent data shows no significant differences in late (years one, two, and three) enrollee-reported toxicity 
outcomes between proton beam therapy and IMRT. The most recent AUA and NCCN guidelines state that PBT 
offers no clinical advantage over other forms of definitive treatment. According to NCCN and ASTRO 
guidelines proton beam therapy may be offered to individuals enrolled in an Institutional Review Board (IRB) 
approved prospective clinical trial or multi-institutional registry that adheres to Medicare requirements for 
camurati-Engelmann disease (CED). 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 proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery radiation therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant of percutaneous Peripheral Nerve Stimulation 
(PNS) lead(s) (placement of Sprint PNS over the cluneal nerves). 
 
You asked the Plan to pre-approve implant of percutaneous PNS lead(s). 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 follows Medicare rules. Medicare rules say that services are only covered when 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 implant of percutaneous PNS lead(s). 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found the enrollee has chronic low back pain. She has tried and failed 
Physical therapy, radiofrequency ablation (RFA) of the sacroiliac (SI) joint as well as steroid injections. The 
enrollee's present medications include Sertaline, Ibuprofen and Percocet. This is considered experimental/ 
investigational therapy. 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 implant of percutaneous PNS lead(s) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implant of percutaneous Peripheral Nerve Stimulation (PNS) lead(s) 
(placement of Sprint PNS over the cluneal nerves).