Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that it is medically necessary that you 
receive more physical therapy. The Plan denied your request. The Plan says there was no evidence that the 
referring provider supports extending the therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
  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 physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the available records, the enrollee with a right 
shoulder rotator cuff injury, s/p repair as above does not meet the Medicare coverage criteria for the requested 
12 additional therapy visits. The documentation does not support the need for additional 12 physical therapy 
visits which are not medically necessary for coverage. In my opinion, additional visits are not medically 
necessary and reasonable based on lack of the physician's support to extend therapy and the enrollee improved 
their shoulder's range of motion and pain doing exercises correctly as documented by physical therapy. 
 
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 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound provided on August 08, 
2022. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you believe you should only be 
charged $35. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for ultrsound. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the ultrsound 
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 reduce the copayment for an ultrasound provided on 
August 08, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 13, 
2022, to June 17, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $325 per 
day, days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 4 days, resulting in a copayment 
amount of $1,300 ($325 per day for 4 days = $1,300). 
 
You have been asked to pay $325 per day, days 1 to 5 for inpatient hospital care. This item/service falls within 
the inpatient hospital care 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 inpatient 
hospital care provided on June 13, 2022, to June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the share cost Medicare-covered visit with a physician 
provided on July 20, 2022. 
 
You asked the Plan to waive the share cost Medicare-covered visit with a physician. You say that you are 
disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $575 
deductible for physician/practitioner services, including doctor's office visits. The allowed amount of these 
services total $466.44, resulting in a deductible amount of $466.44.  
 
You have been asked to pay $466.44 for Medicare-covered visit with a physician. This item/service falls within 
the physician/practitioner services, including doctor's office visits 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 share cost Medicare-covered visit with a physician provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wharton's Jelly. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee with diabetes has a foot wound. He has accompanying pain. The request is for 
use of coretext umbilical cord allograft to treat the wound and pain. This request is considered an experimental 
procedure at this time.  The request is, therefore, deemed not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Wharton's Jelly.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient specialist office visit provided 
on August 23, 2022. 
 
You asked the Plan to waive the copayment for outpatient specialist office visit. You say that you are disputing 
the share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $35 copayment for an outpatient specialist office visit. This item/service falls 
within the physician/practitioner services, including doctor's office visits 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 outpatient specialist office visit provided on August 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service July 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
service is not medically necessary for the enrollee's condition. 
 
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 requested services. Our physician 
reviewer found that the use of IMRT for the treatment of breast cancer is becoming more widely used. For 
those with an intact breast after resection, IMRT has been shown to improve skin and breast toxicity. For post-
mastectomy radiation, IMRT has been shown to significantly reduce the dose-volume exposure of the 
ipsilateral lung and (for left sided breast cancer) the heart. It is plausible that with this enrollees obesity (BMI 
greater than38), IMRT would be necessary for dose homogeneity. In light of the dosimetric improvement with 
IMRT in this enrollee, as well as ASTROs most recent update of its Choosing Wisely list, 15 fractions of 
IMRT followed by a 4-fraction 3D conformal boost (as specified in the letter of appeal) as whole breast IMRT 
would 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve intensity-modulated radiation therapy (IMRT).  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's endurance is significantly impaired and 
requires maximal assistance to complete activities of daily living (ADL) The Plan denied your request. The 
Plan says an IRF admission is not medically necessary. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee may 
need physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services were medically necessary. The Plan denied 
your request. The Plan says there was no prior authorization on file. There are in-network providers to perform 
the services. 
 
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 provided on June 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray provided on August 11, 2022. 
 
You asked the Plan to waive the copayment for x-ray. You say that you are disputing the share cost. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $45 copayment for x-ray. This item/service 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 x-ray provided on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 System continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the CGM. You say that your blood glucose is usually low. You say that it 
would be nice to not have to use the scanner as you are busier these days. You also say that you did not think 
this would be denied and are scrambling with this appeal. The Plan denied your request. The Plan says the 
requested CGM is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Specifically, the requested CGM device does not meet the definition 
of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided 
that the Plan does not have to pre-approve a FreeStyle Libre 3 System continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of an osteogenesis stimulator device. 
 
You asked the Plan to pre-approve osteogenesis device. You say that you have a broken hand. The Plan denied 
your request. The Plan says there has been no evidence of delayed healing of your fracture. 
 
The Plan follows Medicare rules. Medicare rules state that osteogenesis stimulators are only covered if certain 
clinical criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve osteogenesis device. Our reviewer says that you do not meet the Medicare criteria for the requested osteogenesis stimulator. Our physician reviewer 
found records to not document nonunion of a fracture documented by a minimum of two sets of radiographs 
obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days 
showing no clinically significant evidence of fracture healing between the two sets of radiographs as required 
by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteogenesis device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of an osteogenesis stimulator device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services were necessary and were 
reported accurately. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
May 24, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an approved test which was provided for a 
covered indication. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device, expandable controller, 
harness, seat elevation feature, and gel pads for a wheelchair. 
 You asked the Plan to pre-approve wheelchair accessories. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says these accessories are not medically necessary or are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature is not covered by Medicare. 
The rules say that for equipment to be covered, it must primarily serve a medical purpose.   
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records document that the enrollee has 3 out of 5 right upper extremity strength 
with normal tone, and is independent with eating, thus indicating that the enrollee has adequate upper extremity 
strength and function to operate the wheelchair's power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. The requested seat elevation feature is 
excluded from Medicare coverage. The requested gel pads are not covered because they do not serve a purpose 
that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of 
wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection device, expandable controller, harness, seat elevation feature, and gel pads for a 
wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0463 billed for date of service October 21, 2021. 
 
You asked the Plan to pay for code G0463. You say that the Plan should re-review this claim. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 29, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for code G0463 have not been met. Therefore, 
we decided that the Plan does not have to pay for code G0463 billed for date of service October 21, 2021.