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

 
We decided that the Plan does not have to pre-approve twenty-eight (28) fractions of PBT. 
 
You asked the Plan to pre-approve the PBT. You say that the PBT is necessary. The Plan denied your request. 
The Plan says the Medicare rules have not been 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 the PBT. Our physician reviewer found the records do not confirm that metastatic disease to the ulna has been ruled out and the enrollee is not in a 
clinical trial. 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, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
The most recent American Urological Association (AUA) guidelines state that PBRT offers no clinical 
advantage over other forms of definitive treatment. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve twenty-eight (28) fractions of PBT.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36478 billed for date of service November 9, 
2021. 
 
You asked the Plan to pay for procedure code 36478. You say that the claim should be processed. The Plan 
denied your request. The Plan says there are no modifiers allowed with this code pair. 
 
  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 36478 
is a column II code to column I code 36475 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 36478 billed for date of service November 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cologuard test. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements are not met for this case. 
 
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered for enrollees 
between 50 and 85 years of age. 
 
At 97 years of age, the enrollee is out of the age range for this testing. Based on this information, we decided 
that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Cologuard test.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70460 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 70460. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70460 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 70460 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 70460 
billed for date of service March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left breast reconstruction. 
 
You asked the Plan to pre-approve breast reconstruction. You say that asfasfdf The Plan denied your request. 
The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that breast reconstruction is covered for the indications 
established in the applicable LCD. 
 
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 breast reconstruction. Our reviewer 
says that the requested left breast reconstruction is not medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee has breast ptosis after breast reduction 
surgery. The record indicates that the enrollee desires breast symmetry. The requested procedure is cosmetic in 
nature and excluded by rule from coverage. The elements of the coverage criteria are not satisfied.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breast reconstruction have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left breast reconstruction.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 18, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 2, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on May 17, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that lab work should be covered in full. 
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 $21.33 
copayment for Lab services in an outpatient hospital. 
 
You have been asked to pay a $21.33 copayment for lab services. This item/service falls within the Lab 
services in an outpatient hospital 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 
lab services provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided on March 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that your primary care provider did refer you 
to this OON provider. The Plan denied your request. The Plan says the treating provider is not a network 
provider with the Plan and the services were not referred by a network provider. The Plan also says these 
services were not urgent or emergent, nor were they approved in advance. 
 
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 
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 outpatient office visit (99202) provided on 
March 10, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide tablet 9mg ER for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan does not cover outpatient prescription drugs. 
 
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 Budesonide tablet 9mg ER 
for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, 
carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) (CPT code 81275) and KRAS (Kirsten rat 
sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 
146 (81276). 
 
You asked the Plan to pre-approve the laboratory services. You say that you have been diagnosed with cancer 
and it has been caught early on. The Plan denied your request. The Plan says that your request is not medically 
necessary because your records show you have early-stage lung cancer. The Plan states there is no indication 
that your providers are considering chemotherapy. 
 
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 laboratory services. Our physician 
reviewer found the service is reasonable and medically 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 laboratory services have been met. Therefore, we decided that the Plan has 
to pre-approve KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in 
exon 2 (eg, codons 12 and 13) (CPT code 81275) and KRAS (Kirsten rat sarcoma viral oncogene homolog) 
(eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146 (81276).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomographic angiography (CTA) of the lower extremity.

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.

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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that the enrollee had a normal physical exam including normal peripheral pulses and dorsalis pedis bilaterally. The validity of the ankle brachial index  (ABI) at home test cannot be determined based upon a paper report given to the enrollee. In order to qualify for a CTA, a repeat ABI ultrasound by an accredited facility will be needed especially given the normal physical exam including peripheral pulses.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomographic angiography (CTA) of the lower extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4649 billed for date of service January 12, 
2022. 
 
You asked the Plan to pay for procedure code A4649. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code A4649 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4649 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4649 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4649 have not been met. 
 
 
 
  
 Therefore, we decided that the Plan does not have to pay for procedure code A4649 billed for date of service 
January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot and rotational unit, prosthetic leg 
(L5968, L5981). 
 
You asked the Plan to pre-approve an advanced foot and rotational unit, prosthetic leg. You say that the 
proposed prosthesis with flex-walk foot system is the least level of technology available to meet the enrollee's 
functional needs. The Plan denied your request. The Plan says there is no objective clinical documentation to 
support that the enrollee is a K3 ambulator. The request for a K3 foot does not meet Medicare criteria as 
reasonable and 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 an advanced foot and rotational unit, 
prosthetic leg. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found an advanced foot and rotational unit, prosthetic leg 
exceeds the enrollee's medical needs. The 5/2/22 progress note indicates the enrollee has right sciatic pain that 
was severe and limited his ability to attend dialysis. The physician documentation does not support that this 
enrollee's activity level requires the requested K3 level components. The enrollee's activities can be met with a 
lower-level components. 
 
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 advanced foot and rotational unit, prosthetic leg have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an advanced foot and rotational unit, 
prosthetic leg (L5968, L5981).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the home health care services provided from 
March 4, 2022, to March 12, 2022. 
 
You asked the Plan to reimburse you for the services provided. You say that you paid the bill. The Plan denied 
your request. The Plan says proof of payment was not received. 
 
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. The records in the case file do not include a receipt or any other 
documentation to show the services at issue were paid for. Therefore, we decided that the Plan does not have to 
reimburse you for the home health care services provided from March 4, 2022, to March 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, noninvasive, 
spinal applications (E0748). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that the device is medically necessary. 
The Plan denied your request. The Plan says the request cannot be supported for approval and medical 
necessity. 
 
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 an osteogenesis stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had spinal surgery. There has not been enough time (9 months) 
transpired since the surgery and not enough levels have been fused to justify stimulator use. 
 
 
 
 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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, electrical, noninvasive, spinal applications 
(E0748).
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 IRF care 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 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. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) and cone beam computed 
tomography (CT) capture and interpretation with limited field of view  less than one whole jaw (D0364) 
provided May 3, 2022. 
 
You asked the Plan to pay for the limited oral exam and cone beam CT scan. You say that you thought these 
service would be covered, and you cannot afford the extra cost. The Plan denied your request. The Plan says 
these services are not covered under your benefits. 
 
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 pay for the 
limited oral exam (D0140) and cone beam computed tomography (CT) capture and interpretation with limited 
field of view  less than one whole jaw (D0364) provided May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81210, 81328, 81407, 81408, 81479) 
provided on December 16, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you want the Plan to reconsider the denied 
charges for payment. The Plan denied your request. The Plan says the services are not covered because the 
testing was initiated by the laboratory and not by the enrollees treating physician, nor following a consultation 
or evaluation by the enrollees treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating 
the beneficiary are not reasonable and necessary.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Specifically, there is no evidence that the ordering provider 
furnished a consultation related to a specific medical problem or that the results of this testing were intended 
for use in the management of the enrollees condition. Therefore, we decided that the Plan does not have to pay 
for genetic testing (81210, 81328, 81407, 81408, 81479) provided on December 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 25, 2021, to April 30, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the principal diagnosis code did not qualify for 
reporting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code S06.5X9A - traumatic 
subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter. 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 the inpatient hospital services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that progress note from 4/27 states that symptoms are not consistent with syncope as 
the enrollee was conscious during the entire event. The facility reported a loss of consciousness, however the 
record noted the contrary. The review has determined that the records did not support the use of principal 
diagnosis code S06.5X9A - traumatic subdural hemorrhage with loss of consciousness of unspecified duration, 
initial encounter.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 25, 2021, to April 30, 2021.