Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS). 
 
You asked the Plan to pre-approve rTMS. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repetitive transcranial magnetic stimulation (rTMS) is 
only considered medically necessary in adults who have a confirmed diagnosis of major depressive disorder 
(MDD), single or recurrent episode and meet specific criteria. 
 
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 rTMS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the information provided, this 
enrollee does not meet the clinical criteria for the use of Transcranial Magnetic Stimulation (TMS) therapy as 
he had only one visit for psychotherapy and has not had the adequate trial of psychotherapy for the treatment of 
depression in the current episode. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rTMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve repetitive transcranial magnetic stimulation (rTMS).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that the services are medically necessary. Our physician reviewer found while the fact 
remains that this enrollee is in remission and a recent endoscopy revealed no evidence of local tumor 
recurrence, the original surgery revealed a positive tumor margin. Hence, careful surveillance with 
conventional imaging is reasonable. Review of the NCCN guidelines leaves the frequency and necessity of 
imaging surveillance in the hands of the treating clinicians for this particular tumor. The request for 
surveillance CT of the abdomen and pelvis will be at approximately 4 months after the prior scan of June 15, 
2022, and is medically 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 CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.  
 
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 pay for physician's services provided on June 28, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the services 
were not urgent or emergent and the services could have been rendered by a Plan participating provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the level IV - Surgical pathology, gross and microscopic 
examination (88305) and Special stain including interpretation and report (88312) provided on May 11, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the decision and request 
reconsideration of the attached claim because the doctor's office failed to send in a preauthorization form for 
approval. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the level IV - Surgical pathology, gross and 
microscopic examination (88305) and Special stain including interpretation and report (88312) provided on 
May 11, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies for the enrollee. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the enrollee is not using insulin shots three or more times a day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy, 60 minutes, (90837) provided on January 
27, 2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that the claim should be paid. The Plan 
denied your request. The Plan says there was no documented contact with the attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy service have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy, 60 minutes, 
(90837) provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient domiciliary, rest home, or custodial 
care visit (99335) provided on February 17, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary, rest home, or custodial care visit. You say that please understand 
that it was medically necessary for the enrollee to receive the treatment and you did not know that the facility 
failed to get preauthorization. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the established patient domiciliary, rest home, or 
custodial care visit (99335) provided on February 17, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from May 3, 
2022, through May 4, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
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 provided 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 
(A9270) provided from May 3, 2022, through May 4, 2022.  Benefits for these items 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will benefit from admission to an IRF. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that you do not have any complex nursing or rehabilitation needs. Medically 
necessary care can be provided in a different level 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
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 a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You were recently hospitalized with exacerbation of heart failure with preserved ejection fraction 
(HFpEF), and arterial blood gases (ABG) was consistent with chronic carbon dioxide (CO2) retention, mild. 
This is presumed obesity-hypoventilation syndrome (OHS), and likely obstructive sleep apnea (OSA). There is 
no diagnosis of chronic obstructive pulmonary disease (COPD), neuromuscular disease, or thoracic restrictive disease. You may benefit from continuous positive airway pressure (CPAP) or bilevel positive airway pressure 
(BiPAP) during sleep. But Medicare does not cover a home ventilator for the treatment of OHS, or when used 
as BiPAP. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services provided from August 3, 2021, to 
February 22, 2022. 
 
You asked the Plan to pay for behavioral health services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for behavioral health services provided from August 3, 2021, to 
February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve the requested device. You say that this device is medically necessary. The 
Plan denied your request. The Plan says you do not meet all the required coverage criteria for this device. 
 
The Plan must follow Medicare rules. Medicare rules requires all the criteria listed in the Medicare rules 
section to be met for coverage to be approved. Based on the medical records provided, you are not insulin-
treated with multiple (three or more) daily administrations of insulin, and you do not meet all the criteria listed. 
Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor and supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the admission to a SNF is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. 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 lab services provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204), x-rays of the knee (73564), aspiration 
and/or injection of fluid from large joint (20610), and corticosteroid injections (J3301) provided on May 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit, imaging services, and injections. You say that the services 
rendered to the enrollee are medically necessary. The Plan denied your request. The Plan says the rendering 
provider is out-of-network, and the claim does not meet the urgent or emergent criteria for coverage. The Plan 
also says that there is no documentation to support that the enrollee was referred by a contracted provider, nor 
is there evidence that an attempt to obtain a prior authorization was made. The Plan says there are in-network 
providers available within the time and distance guidelines set by Medicare. 
  
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99204), x-rays of the knee (73564), 
aspiration and/or injection of fluid from large joint (20610), and corticosteroid injections (J3301) provided on 
May 24, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a DTRAX spinal system facet joint spacer. 
 
You asked the Plan to pre-approve a DTRAX spinal system facet joint spacer. 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 a DTRAX spinal system facet joint 
spacer. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the DTRAX cervical facet spacer device is experimental. 
More research is needed. 
 
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 DTRAX spinal system facet joint spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a DTRAX spinal system facet joint spacer.
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 1, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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 1, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on May 24, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that the ambulance service provided immediate 
treatment to you. You say that they brought you out of a coma. You also say that the transport was not 
necessary. The Plan denied your request. The Plan says since there was no transport provided, there is no 
payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 24, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on May 24, 2022.