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

 
We decided that the Plan does not have to reduce the copayment for the denosumab injection provided on 
March 31, 2022. 
 
You asked the Plan to reduce the copayment for the denosumab injection. You say that being billed this much 
for a shot is not right. You say that you should not have to pay this much. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% of the total cost for Part B drugs.  
 
The enrollee has been asked to pay a $254.52 coinsurance for Part B drugs (1272.60 the allowed amount x 20% 
coinsurance = $254.52). A denosumab injection falls within the Medicare Part B Prescription Drugs benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the denosumab injection 
provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the portable ventilator is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer 
says that the portable ventilator is not medically necessary. Our physician reviewer found the clinical 
documentation does not support a diagnosis of chronic respiratory failure. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services received on September 22, 2018. 
 
You asked the Plan to pay for the services. You say that you were unaware of this bill until it was sent to a 
collection agency. The Plan denied your request. The Plan says that the provider's Medicare number and copy 
of certification was requested and never received. 
 
Medicare says that plans must pay for emergency and urgently needed services.  
 
You had an emergency and received reasonable services. The code billed - CPT 99285 - indicates that the 
emergency problems were of high severity. You have no control over how this claim was billed and you are not 
responsible for this payment. Based on this information, we decided that Medicare rules for coverage of the 
services have been met. Therefore, we decided that the Plan has to pay for emergency room services received 
on September 22, 2018.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve ultraviolet light therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there needs to be clinical notes showing the psoriasis has not responded to 
treatment, and are unable to receive treatment in the office. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found your type of psoariasis responds very well to a combination of high potency topical corticosteroid, which 
the enrollee has already been prescribed (clobetasol), with phototherapy. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve ultraviolet light therapy.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get back to your baseline. The Plan 
denied your request. The Plan says the records do not support the need for an intensive rehabilitation therapy 
program. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for surgical repair of the hip after a fall. Your medical problems are 
stable. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 
 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care. 
 
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 physician 
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. The health plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you need physical therapy 3 times a week. The 
Plan denied your request. The Plan says your request goes beyond your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 11, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says this claim was not timely filed. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until March 21, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical services provided on February 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs close monitoring with 
transfusions as needed. The Plan denied your request. The Plan says the LTACH would add no additional 
services. 
 
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 physician 
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. The health plan has approved ongoing care in the current acute 
care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs oxygen weaning, lab 
monitoring, and intravenous antibiotics. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care. 
 
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 physician 
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that the enrollee requires that are not available 
at the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on January 17, 2022. 
 
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 that procedure code 22854 is not supported by the medical records submitted. 
 
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 22854 is "Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral 
anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral 
corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody 
arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)." 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that a review of the operative procedure 
documented that "Alphatec PEEK interbody cage...for interbody fusion.."... Alphatec anterior cervical plate 
was applied from C4-7 and then variable angle locking screws were final tightened to the plate. Therefore, the 
records do support that CPT 22854: insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, 
mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to 
vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody 
arthrodesis, each contiguous defect (list separately in addition to code for primary procedure)- was rendered in 
this case. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
surgical services provided to the enrollee on January 17, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found billing for daily IGRT for skin cancer would not be furnished in accordance with 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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guided radiation therapy (IGRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 6, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service February 6, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 9, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service November 9, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 1, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery. 
 
You asked the Plan to pre-approve proton treatment delivery. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 proton therapy for prostate cancer is not experimental, and in fact is an accepted 
treatment approach. While it is not believed that proton therapy is an experimental therapy, any potential 
benefit or detriment of proton therapy over standard Intensity-modulated radiation therapy (IMRT) is an 
investigational question. Other treatment approaches Intensity-modulated radiation therapy/Image-guided 
radiation therapy (IMRT +/- IGRT) are also highly effective and well tolerated. Thus, whether proton therapy 
affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an area of investigation 
and remains controversial. To date, there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer 
proton beam therapy on clinical trials, and to not routinely offer it to enrollees.  
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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service March 28, 2022.