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

 
We decided that the Plan does not have to pay for shockwave therapy (0101T) provided on June 27, 2022 to 
September 2, 2022. 
 
You asked the Plan to pay for the shockwave therapy. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 0101T is not supported in the medical record. Specifically, the medical records 
provided do not include sufficient documentation to validate that the services provided. Based on this 
information, we decided that Medicare rules for coverage of the shockwave therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for shockwave therapy (0101T) provided on June 27, 
2022 to September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
  You asked the Plan to pre-approve facet joint injections. You say that the procedure has helped the enrollee 
manage pain and daily activity in the past. The Plan denied your request. The Plan says the facet joint 
injections requested do not meet the requirements for approval. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation as to why radiofrequency ablation cannot be performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system. 
 
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 a flex-walk system 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 that the documentation does not 
support that the enrollee is able to ambulate at the K3 level. The criteria for coverage are not met and the 
requested upgraded flex-walk system is not reasonable or medically necessary at this time. 
 
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 a flex-walk system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says the enrollee does not meet the guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is still somewhat unstable and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 8, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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 sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESIs) (64483, 64484 x 2). 
 
You asked the Plan to pre-approve injections. You say that the enrollee has seen multiple providers including 
chiropractors, pain management, physical therapists who all advised the enrollee they are not making progress. 
You say that this is the next step for relief. You also say that the enrollee has been using the home exercise program they were given six months ago at urgent care. The Plan denied your request. The Plan says the 
enrollee has not completed at least four weeks of noninvasive conservative care. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain 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 injections. Our reviewer says that the 
requested injections are not medically necessary. Our physician reviewer found the provided documentation 
indicates a diagnosis of lumbar radiculopathy. The reviewer found that you reported not completing 4 weeks of 
conservative treatment in the form of physical therapy or chiropractic care. Therefore, the reviewer found that 
the requested injections are not medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve epidural steroid injections (ESIs) (64483, 64484 x 2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
grade III meningioma that was previously resected with residual non-resectable disease. The Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare-approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. The records provided indicate that the requested drug is not intended to 
be prescribed at the time of the documentation. Keytruda is not reasonable and medically necessary and safe 
and effective based on the submitted documentation.  
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 Keytruda.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an anti-cancer regimen comprising carboplatin, Taxol, 
nivolumab and ipilimumab. 
 
You asked the Plan to pre-approve carboplatin, Taxol, nivolumab and ipilimumab. You say that the requested 
regimen is a medical necessity for you. The Plan denied your request. The Plan says the requested regimen has 
been prescribed for an off-label, not medically accepted use. 
 
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 carboplatin, Taxol, nivolumab and 
ipilimumab. Our reviewer says that the requested regimen is not medically reasonable and necessary in this 
case. Our physician reviewer found that the requested use of carboplatin, Taxol, nivolumab and ipilimumab is 
not FDA-approved for the enrollees diagnosis and clinical situation. The use is not supported by one of the 
major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carboplatin, Taxol, nivolumab and ipilimumab have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an anti-cancer regimen comprising carboplatin, Taxol, 
nivolumab and ipilimumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic therapy services provided from February 23, 
2022, to March 30, 2022. 
 
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says this 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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic therapy services provided from February 23, 2022, to 
March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on September 8, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services billed. 
 
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, the CPT Code Manual definition of code 99223 is evaluation and management of a patient, 
requiring three key components: a comprehensive history, a comprehensive examination and medical decision 
making of high complexity. 
 
We asked our coder 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 physician services. Our reviewer says that the provided 
records do not support the billed code. Our reviewer found high complexity requires an extensive number of 
diagnoses or management options, an extensive amount and complexity of data reviewed, and high risk of complication. The records provided do not support medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid treatment program (OTP) services provided on 
September 26, 2022. 
 
You asked the Plan to pay for the OTP services. The Plan denied your request. The Plan says this provider is 
not payable for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities.  
 
We looked at the file and Medicare rules. The provider in this case is not eligible to bill for OTP services. 
Individual providers are not payable for OTP services. Based on this information, we decided that Medicare 
rules for coverage of the OTP services have not been met. Therefore, we decided that the Plan does not have to 
pay for the opioid treatment program (OTP) services provided on September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service October 25, 
2022. 
 
You asked the Plan to pay for procedure code G0480. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G0480 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0480 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0480 billed for date of service October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse replacement crowns provided on October 5, 2022. 
 
You asked the Plan to reimburse replacement crowns. You say that you would like reimbursement for this. 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). 
 
You have been asked to pay for replacement crowns. The Plan agreed to issue a refund for $1,782.50. 
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 reimburse replacement crowns provided on October 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ProACT periurethral balloon continence device. 
 
You asked the Plan to pre-approve the ProACT periurethral balloon continence device. You say that ProAct 
therapy is not investigational or experimental and should be covered when medically necessary. The Plan 
denied your request. The Plan says the ProACT periurethral balloon continence device is not considered 
reasonable and 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 ProACT periurethral balloon 
continence device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the ProAct device has not been scientifically shown to 
be beneficial as a medically appropriate alternative to an artificial urinary sphincter. 
 
 
  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 ProACT periurethral balloon continence device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the ProACT periurethral balloon continence 
device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the flu shot provided on October 22, 2022. 
 
You asked the Plan to pay for the flu shot. You say that the service should be covered. The Plan denied your 
request. The Plan says that a valid National Provider Identifier (NPI) was not submitted. 
 
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 has not provided any information on why the billed NPI is not correct. 
Therefore, we decided that the Plan has to pay for the flu shot provided on October 22, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 15, 2022, to 
May 20, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.02, described as 
sepsis due to methicillin resistant staphylococcus aureus, and secondary diagnosis code R65.20, described as 
severe sepsis without septic shock. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
codes. 
 Our physician reviewer found the enrollee is a 61-year-old male with a past medical history including 
hypertension, diabetes mellitus and previous stroke who was admitted to the hospital with weakness and 
malaise with a draining wound. He was diagnosed and treated for an abscess to the right lower quadrant. He 
was treated with an incision and drainage of the abscess and parental antibiotics. He responded appropriately to 
treatment and stabilized. There was no evidence of life-threatening organ dysfunction due to dysregulated host 
response to an infection or persistent hemodynamic instability. 
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 15, 2022, to May 20, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient mental health treatment provided from 
July 16, 2022, through July 21, 2022. 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient mental health 
treatment provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient mental health treatment provided was not medically necessary. Our physician reviewer found 
that the progress notes do not indicate that the enrollee had been aggressive with peers or staff on the unit or 
had any recent attempts to harm herself at the time of admission. There was no indication in the available 
medical records that the enrollees psychiatric symptoms could not be managed on a less restrictive basis. She 
was noted to have confusion at her baseline mental status. The enrollee was not exhibiting any other significant 
symptoms such as psychosis or mania. She had no acute psychiatric issues that would require inpatient care. 
The enrollee has chronic symptoms. The available medical records do not support that inpatient care would 
have changed these symptoms or the enrollees current condition. The enrollee is chronically impaired due to 
vascular dementia and the inpatient hospital stay was not expected to improve her condition in a reasonable 
period of time. 
 
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 pay for the acute inpatient mental health treatment provided from July 16, 2022, through July 21, 2022.