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

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 87640. You say that this service is supported in the medical 
record and should be paid separately. The Plan denied your request. The Plan says the payment for code 87640 
is included in the payment for code 87641. Although a modifier was used in this case, the medical records 
provided do not support that this modifier was used correctly. 
 
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 87640 
is a column II code to column I code 87641; however, 87640 was billed with a modifier.  
 
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 procedure code 87640. Our reviewer says that the use of the 
59 modifier is not appropriate in this case. Our reviewer found the laboratory report does not include 
documentation to support 87640 was a separate procedure from 87641, and therefore denied correctly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87640 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87640 billed for date of service September 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee would benefit from this 
procedure. The Plan denied your request. The Plan says there is insufficient evidence to support this procedure. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) of the spine shows severe foraminal stenosis. 
As such, the cause of the pain remains unclear. This procedure is not medically appropriate 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept basivertebral nerve ablation procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the proton beam therapy (PBT) (77387, 77525 and G6002). 
 
You asked the Plan to pre-approve the PBT. You say that the services are medically necessary. The Plan denied 
your request. The Plan says that there is no current research showing that the enrollee's type of cancer responds 
better to the requested type of treatment than the type of treatment we can approve. The Plan states this type of 
treatment is called 3D-CRT (three-dimensional conformal radiation therapy). The Plan states it matches the 
target and uses beams of energy to damage cancer cells to stop their growth. 3D-CRT would be approved if 
requested. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PBT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found while any potential benefit of proton therapy over standard intensity-modulated radiation 
therapy (IMRT) is investigational, with the dosimetric differences described, it is plausible that there would be 
a benefit in this enrollee. Our physician reviewer's decision is favorable as the treatment would be in 
accordance with accepted standards of care. 
 
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 PBT have been met. Therefore, we decided that the Plan has to pre-approve 
the proton beam therapy (PBT) (77387, 77525 and G6002).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop reader (ILR) (33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says a subcutaneous cardiac rhythm monitor is considered reasonable and necessary when you have episodes of syncope (loss of consciousness) that are thought to be cardiac-related but do not 
happen often enough to be detected by a Holter monitor (portable device to record heart rhythms). The Plan 
states the clinical information provided to the Plan shows no history of or recent episodes of syncope. 
 
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 ILR. Our physician reviewer found 
insertion of an ILR would not be considered medically appropriate and necessary in your clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the implantable loop reader (ILR) (33285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tooth extractions. 
 
You asked the Plan to pre-approve the dental services. You say that full dental extractions would limit the time 
the enrollee is off their chemotherapy treatment. The Plan denied your request. The Plan says this service is not 
covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Additionally, this service would not be covered under the enrollees 
medical benefit because they are not extractions to prepare the jaw for radiation treatments. Therefore, we 
decided that the Plan does not have to pre-approve tooth extractions.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection device (E2311). 
 
You asked the Plan to pre-approve an electronic connection device. You say that the connection device is 
medically necessary. The Plan denied your request. The Plan says that that there is not a medical need to 
control the power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that an electronic connection device is covered when it is 
medically necessary to control the power options through the joystick. 
 
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 electronic connection device. Our 
reviewer says that the coverage criteria has been met. Our physician reviewer found that the enrollee is non-
ambulatory and requires a power wheelchair for mobility and performing his basic daily activities. The enrollee 
cannot perform pressure relief independently due to weakness and requires a power wheelchair with power tilt. 
In order to appropriately operate the power tilt function of the power wheelchair the enrollee requires an 
electronic connection that integrates with the wheelchair's joystick, which is required to operate the power 
wheelchair. 
 
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 electronic connection device have been met. Therefore, we decided that the 
Plan has to pre-approve an electronic connection device (E2311).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration for the 
denial and have provided medical records for review. The Plan denied your request. The Plan says the records 
do not show that the enrollee failed BiPap. Records indicate the enrollee was treated with BiPap in the 
emergency department, improved, and was weaned to nasal cannula. The provider is requesting NIV to be used 
exclusively in a BiPap mode. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the 
Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on September 26, 2022, billed 
with code 74018-26-77. 
 You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this code is bundled into payment for procedure 
code 74250. 
 
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 74018 is a column II code to column I code 74250; however, 74018 
was billed with a modifier.  
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code Our reviewer found the documentation does not support this 
being billed separately or as an additional repeat procedure. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on September 26, 2022, billed with code 74018-
26-77.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires daily oversight by a physician 
and dietary consults due to their acute and chronic medical conditions. The Plan denied your request. The Plan 
says the enrollee can safely receive the services in another setting. 
 
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 does not need physician supervision 3 times per week for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While the enrollee may 
benefit from physical and occupational therapy, their therapy needs can safely be provided in an alternate 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided October 23, 2022, to 
November 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary while the enrollee was out of the country. The Plan denied your request. The Plan says that these 
services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record show that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided October 23, 2022, to November 8, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye surgery provided on November 21, 2022. 
 
You asked the Plan to pay for eye surgery. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for eye surgery provided on 
November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery (77523). 
 
You asked the Plan to pre-approve proton treatment delivery. You say that you disagree with the denial and 
request reconsideration due to prostate cancer. The Plan denied your request. The Plan says a review of the 
literature indicates that PBRT is not the standard of care for prostate cancer and Proton Beam therapy for 
primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial. 
 
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 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, IMRT, or brachytherapy with regards to safety and efficacy. Recent data shows no 
significant differences in late (years one, two, and three) patient-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 IRB approved prospective clinical trial or multi-
institutional registry that adheres to Medicare requirements for CED. The records show that the enrollee is 
enrolled in an enrollee registry but not enrolled in an interventional clinical trial. 
 
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 (77523).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that the enrollee needs the oxygen support 
of a ventilator. The Plan denied your request. The Plan says a lesser device can provide the support needed. 
 
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 requested ventilator. Our reviewer 
says that the ventilator requested is not considered medically reasonable and necessary. Our physician reviewer found the enrollee is a 70-year-old patient with a diagnosis of chronic hypercapnic respiratory failure with 
suspected obstructive sleep apnea and obesity hypoventilation syndrome. A home mechanical ventilator has 
been requested.  
 
The records document that the home ventilator is being requested for use in intelligent volume assured pressure 
support (IVAPS) mode with auto-titration (AE) which could be provided by a bilevel positive airway pressure 
(BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. Provided records 
do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As such, the requested 
device exceeds the enrollee's medical need. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says criteria are not met as no daily skilled needs have been identified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.