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

 
We decided that the Plan does not have to pre-approve injection of substance into lower spine canal using 
imaging guidance (CPT code 62323). 
 
You asked the Plan to pre-approve the injection. You say that the service is necessary. The Plan denied your 
request. The Plan says prior to a repeat injection, there must be at least 50% sustained improvement in pain 
relief and/or improvement in function for at least three (3) months. The Plan states that in this case, it is noted 
that you had improvement in pain for only six (6) weeks. 
 
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 injection. Our physician reviewer 
found you did not meet the criteria of 50% for three (3) months. Therefore, the request is deemed not medically 
reasonable or necessary. There are other evidence-based therapies available to you. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection of substance into lower spine canal using imaging guidance (CPT code 62323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve removal of torus mandibularis. You say that the service at issue is medically 
necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
removal of torus mandibularis (D7473).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of uterine tubes (CPT code 58700). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is presently using combined oral 
contraceptive pills for contraception. You state the enrollee is a smoker; given their age, tobacco use, and lack 
of mobility, the enrollee is at increased risk for cardiovascular or thromboembolic events while using combined 
oral contraceptive pills. You state the enrollee does not desire future childbearing. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met.  The primary indication for the 
enrollee's elective permanent sterilization (laparoscopic bilateral salpingectomy) is for contraceptive purposes and not to treat an illness or injury. Therefore, the requested service cannot be covered. Therefore, we decided 
that the Plan does not have to pre-approve removal of uterine tubes (CPT code 58700).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the service. You say that you are a good candidate for spinal cord 
stimulation based on the current practice guidelines, including the failure of multiple conservative treatment 
options. You state the spinal cord stimulation is medically necessary for your medical condition. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show that you 
have persistent pain problems despite a prior spinal cord stimulator. The Plan states with respect to your 
persistent chronic pain issues, your records indicate that you have not had recent psychological screening, 
evaluation, or treatment/therapy to try to improve your pain or pain perception. The Plan states your old 
psychological evaluation from two (2) years ago does not meet this Medicare guidance; at that time, you had 
significant anxiety, depression, and memory problems documented. 
 
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 service. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the NCD/LCD for Medicare 
Coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the carpectomy (25210) provided on September 22, 2021. 
 
You asked the Plan to pay for the carpectomy. You say that the documentation supports the use of the -59 
modifier. The Plan denied your request. The Plan says this code is included in the payment for another service 
performed.  
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 25210 is a column II code to column I code 25447; however, 25210 
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 carpectomy. Our reviewer says that the documentation 
does not support the use of the -59 modifier to bypass the edit. Our reviewer found the provider reported 
modifier 59. Documentation submitted was reviewed, and the criteria for coverage have not been met. 
Operative report does not document both carpal bones were removed. CPT 25210 bundles to CPT 25447 as one 
of the carpal bones is removed in an interposition arthroplasty. Therefore, modifier -59 is not supported 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 carpectomy have not been met. Therefore, we decided that the Plan does not 
have to pay for the carpectomy (25210) provided on September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the small intestine suture (44602) provided on May 17, 2021. 
 
You asked the Plan to pay for the small intestine suture (44602). You say that procedure code 44602 was a 
separate location of ulcer that was over sewn. You say that procedure code 44602 should be reprocessed for 
payment. The Plan denied your request. The Plan says CPT code 44602 is not supported in the documentation 
and is not payable. 
 
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 44602 is suture of small intestine (enterorrhaphy) for 
perforated ulcer, diverticulum, wound, injury or rupture; single perforation. 
 
  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 small intestine suture (44602). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report does not describe a small bowel perforation was identified and repaired with sutures. The 
operative report describes ulceration was approximated with clips. Therefore, this procedure cannot be verified. 
 
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 small intestine suture (44602) have not been met. Therefore, we decided that 
the Plan does not have to pay for the small intestine suture (44602) provided on May 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the proton treatment delivery; simple, with 
compensation (CPT code 77522). 
 
You asked the Plan to pre-approve the services. You say that proton beam radiation therapy is needed. The 
Plan denied your request. The Plan says a review of the current medical literature indicates that this service is 
considered experimental and investigational as it is not identified as widely used and generally accepted for the 
proposed use as reported in nationally recognized peer-reviewed medical literature published in the English 
language nor is it recommended by the professional association guidelines. The Plan states that studies have 
shown no additional benefit or decrease in adverse effects with proton beam radiation therapy (PBRT) over 
intensity-modulated radiation therapy (IMRT). The Plan states the treatment is not proven to be as beneficial as 
the existing and available current medical standard. 
 
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 services. 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 compelling data to suggest that proton therapy is superior to or more beneficial 
than IMRT/image-guided radiation therapy (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 patients.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the proton treatment delivery; simple, with compensation (CPT code 77522).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enterade. 
 
You asked the Plan to pre-approve Enterade. You say that this is needed to help following chemotherapy 
treatment. You say that you are experiencing nausea and diarrhea. You say that the dieticians have 
recommended this to help ease the process of the chemotherapy. The Plan denied your request. The Plan says 
Enterade is classified as a medical food and is not covered under Medicare or the enrollee's contract. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Enterade.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dronabinol Cap 2.5MG (CPT code J8597). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this medication is not being administered Dronabinol with cancer chemotherapy 
treatment that is initiated within two (2) hours of the administration of chemotherapy. The Plan states 
Dronabinol will be continued for a period exceeding forty-eight (48) hours from that time, nor is it being used 
as a full therapeutic replacement for intravenous (IV) anti-emetic drugs that would have been administered at 
the time of the cancer chemotherapy treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our physician reviewer 
found the review has determined that the documentation does not support that the Dronabinol is medically 
reasonable and necessary. The documentation does not support that the Dronabinol is safe and effective. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Dronabinol Cap 2.5MG (CPT code J8597).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for subsequent hospital inpatient care provided 
from September 9, 2021, to September 10, 2021. 
 
You asked the Plan to waive the deductible for subsequent hospital inpatient care. You say that you had other 
dates of service with a different provider that were similar to billing code 99232. You also say that those claims 
processed according to the allowable, and you would like a refund for the amount paid of $140.12. 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. Your 
contract with the Plan says that there is $1,000 deductible which applies to in and out of network inpatient 
hospital care.  
 
The deductible amounts you are being asked to pay are the same as the allowed amounts for the services. The 
deductible was not met as of September 9, 2021, and September 10, 2021, when you received inpatient care. 
The subsequent hospital inpatient care you asked the Plan to waive the deductible for falls within the Inpatient 
Hospital Care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation 
that had not been met at the time subsequent hospital inpatient care was received on September 9, 2021, to 
September 10, 2021. Therefore, we decided that the Plan does not have to waive the deductible for subsequent 
hospital inpatient care provided from September 9, 2021, to September 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wellbutrin 300MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Wellbutrin 300MG tablet to be administered at home is not Medicare covered 
under the Part A or B benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Wellbutrin 300MG tablet.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
October 28, 2021. 
 
You asked the Plan to waive the copayment for an EKG. You say that you have had an EKG in the same visit 
with your doctor many times over the last five years. You say that you already paid your $40 specialist 
copayment at the time of service. 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). Your contract with the Plan clearly says that you must pay a $30 
copayment for in-network non-radiological diagnostic services, including EKGs.  
 
 You had an electrocardiogram on October 28, 2021, which is a separately payable service. You have been 
asked to pay the allowed amount of $16.49, which is less than the $30 copayment for an EKG. An EKG falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an electrocardiogram (EKG) provided on October 28, 2021.  
 
Your complaint about your insurance companys service is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ExoDx Prostate IntelliScore testing (0005U). 
 
You asked the Plan to pre-approve the ExoDx Prostate IntelliScore testing. You say that this test is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that this test is covered ONCE in men 45 years old 
and up prior to initial biopsy, with confirmed moderately elevated PSA (Greater than 3 ng/mL, but less than 10 
ng/mL). 
 
We looked at the file and Medicare rules. The rules show the enrollee's PSA is greater than 10 ng/mL. Based 
on this information, we decided that Medicare rules for coverage of the ExoDx Prostate IntelliScore testing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve ExoDx Prostate 
IntelliScore testing (0005U).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on October 29, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the self-administered drugs provided 
during your outpatient stay are not covered under your Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on October 29, 2021.  
 Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
May 21, 2021, through June 16, 2021. 
 
You asked the Plan to pay for the subsequent nursing facility services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim for these 
services was previously processed and paid. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the subsequent nursing facility care 
(99309) provided on May 21, 2021, through June 16, 2021. have been met. Specifically, the record shows that 
the Plan previously processed and paid the claim for CPT code 99309 billed by the same provider for May 21, 
2021, through June 16, 2021. The documentation submitted does not indicate that these services were rendered 
more than once per day on the billed dates of service. Therefore, we decided that the Plan does not have to pay 
for the subsequent nursing facility care (99309) provided on May 21, 2021, through June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on June 12, 
2021. 
 
You asked the Plan to pay for code 99232. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. In this case, there were no medical records provided for review to determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the 
subsequent hospital care (99232) provided on June 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested power 
scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that the written order prior to delivery (WOPD) for 
the base item may only be written after the completion of the face-to-face encounter.   
The file does not show that you have had a face-to-face encounter regarding the power scooter. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 18, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 laboratory services provided on August 18, 2021.