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

 
We decided that the Plan has to pay for psychotherapy services (90837) provided on October 15 and October 
20, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the clinical psychologist or clinical social worker 
will attempt to consult with the enrollee's attending or primary care physician, except where the physician has 
referred the enrollee to the clinical psychologist or clinical social worker. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have been met. Specifically, the record clearly indicates that the enrollee 
was referred for the services at issue by a physician. The rules regarding consultation with the enrollee's 
attending or primary care physician do not apply if a physician has referred the enrollee to the clinical 
psychologist. Therefore, we decided that the Plan has to pay for psychotherapy services (90837) provided on 
October 15 and October 20, 2021.  
 
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 Periodic comprehensive preventive medicine (99397) 
handling and/or conveyance of specimen for transfer from the physicians office to a laboratory (99000) 
provided November 12, 2021. 
 
You asked the Plan to pay for the office visit. You say that it was a few days over one year from your last 
ob/gyn exam and pap smear. Please reconsider as you are being charged $135.00. The Plan denied your 
request. The Plan says the yearly maximum benefit is exhausted. 
 
The Plan follows Medicare rules. The rules say that a Cost plan must disclose in writing all benefits available 
under the Plan. The health Plan contract says that pap tests and pelvic exams are covered once every 24 
months.  
 
Based on review of the file, this service was provided less than 24 months prior to the visit at issue in this case. 
The records show that this service was previously provided and paid for by the Plan for date of service November 10, 2020. Therefore, we decided that the Plan does not have to pay for Periodic comprehensive 
preventive medicine (99397) handling and/or conveyance of specimen for transfer from the physicians office 
to a laboratory (99000) provided November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on March 15, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed codes 
cannot be verified.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The claim shows the gene panel provided was billed with multiple codes. If 
a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the 
procedure. The claim also lists a place of service as an independent laboratory. If an independent lab bills for 
services, the place where the sample was taken is reported as the POS. The records do not show that the 
specimen was obtained at the independent laboratory. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the gene panel testing provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve immune globulin, (gammagard liquid), non-lyophilized, (e.g., 
liquid), 500MG injection (CPT code J1569). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that 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 service. Our physician reviewer 
found patients with myeloma are at increased risk for infection. This patient has recurrent sinopulmonary 
infections despite antibiotics and is at increased risk for recurrent infections. IgA level is very low. Above 
criteria is met. IVIG is reasonable and medical necessary for this patient. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500MG injection (CPT code 
J1569).  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 the drug testing services provided on February 25, 2021. 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
services were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that definitive drug testing was provided. The claim lists a place of service as an independent 
laboratory. If an independent lab bills for services, the place where the sample was taken is reported as the 
place of service. We find that the specimen was not obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the 
member has suffered from this condition for over a year and has failed more than 6 months of conservative 
approaches to treatment. You say that your patient is a good candidate, and this treatment is considered safe 
and effective. The Plan denied your request. The Plan says unproven and not medically necessary procedures 
are not covered. 
 
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 insertion of stabilization device 
(22869 and 22870). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is a lack of large volume, long-term 
peer-reviewed outcome studies to support the use of this device for this enrollees medical condition. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 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 insertion of stabilization device (22869 and 22870) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 
and 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (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 IRF care is not supported based on the records received. The Plan says that the 
enrollee's needs can be safely met in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical conditions are stable on outpatient medications with antibiotics with dialysis three times per week and 
with no other issues that require a physicians evaluation three or more times per week. The enrollee does 
require physical therapy and occupational therapy services, but the medical records provided do not clarify why 
the enrollee requires an intensive inpatient rehabilitation therapy program. Provided records do not explain why 
the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such 
as in a skilled nursing facility is not appropriate for the enrollee. Based on the medical records provided, there 
is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility due to his severe mobility imitations. Care at the 
skilled nursing facility level appears to be appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has macular degeneration. 
He has not tried and failed the Plan's required drug, Avastin. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Eylea is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650), cervical collar (L0174), and 
shoulder immobilizer (L3670), provided on October 19, 2021. 
 
You asked the Plan to pay for the back brace, cervical collar, and shoulder immobilize. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the member obtained this item through an 
unsolicited call. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules.  
 The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, 
and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show 
that written permission was obtained to make contact by telephone regarding the furnishing of this item. The 
record does not show that contact was initiated regarding an item already furnished to the enrollee or another 
item furnished to the same enrollee within the past 15 months. Based on this information, we decided that 
Medicare rules for coverage of the back brace, cervical collar, and shoulder immobilize have not been met. 
Therefore, we decided that the Plan does not have to pay for the back brace (L0650), cervical collar (L0174), 
and shoulder immobilizer (L3670), provided on October 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox 300 units per treatment for the enrollee. 
 
You asked the Plan to pre-approve Botox 300 units per treatment. You say that this is medically necessary. The 
Plan denied your request. The Plan says that the recommended dose is 200 Units of Botox per treatment and 
should not be exceeded. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox 300 units per treatment. Our 
reviewer says that Botox 300 units per treatment is not medically reasonable and necessary. The enrollee has a 
diagnosis of neurogenic bladder with detrusor overactivity. The Food and Drug Administration has stated that 
the maximum dosage of Botox is 200 units per treatment for the enrollee's condition. The medical records 
provided indicate that the provider is using the Food and Drug Administration's maximum dose. The Food and 
Drug Administration has not stated that the requested drug dose is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug dose 
in the enrollee's clinical situation. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of Botox 300 units per 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 Botox 300 units per treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Botox 300 units per treatment for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on March 25, 2021. 
 
You asked the Plan to pay for the compression stockings. You say that you need this item. The Plan denied 
your request. The Plan says this is not a covered item. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (83789) provided on July 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service.  
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 83789 
is a column II code to column I code 80307. 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 the services (83789) provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight manual wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 wheelchair. Our reviewer says that 
the requested iservices are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation is conflicting that the enrollee has a mobility limitation that significantly 
impairs the ability to complete MRADLs. The 1/3/22 medical progress note indicates that the enrollee is 
ambulating normally, and has normal gait and station. The physical therapy notes indicate that the enrollee has 
steady gait with a hemi-walker, and needs a manual wheelchair in the community. The documentation does not 
clearly consistently reveal that the requested wheelchair will significantly improve MRADL participation in the 
home. The physician note states that a regular wheelchair is too heavy of the enrollee to self propel but the 
documentation does not reveal a trial of a regular wheelchair or that the requested lightweight manual 
wheelchair is 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight manual wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac genetic testing provided on August 26, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiac 
genetic testing provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccination (90471 and 90750) provided on 
November 24, 2021. 
 
You asked the Plan to pay for the shingles vaccination. You say that you would like reconsideration because 
you were not told that this service would not be covered. The Plan denied your request. The Plan says the 
Shingles vaccine is a Part D drug in which is not a covered benefit under this medical plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles 
vaccination. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccination. Therefore, we decided that the Plan does not have to pay for the shingles vaccination (90471 and 
90750) provided on November 24, 2021.  
 
Benefits for the shingles vaccination 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each 
additional 15 minutes (97811) provided September 8, 2021. 
 You asked the Plan to pay for the acupuncture services. You say that you request that after reviewing the 
attached medical records that all services be reprocessed and paid. The Plan denied your request. The Plan says 
the services were rendered by a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the health Plan contract says that the services must be 
provided by a legally qualified physician practicing within the scope of their license. The services were 
rendered by a licensed acupuncturist and not physician. Therefore, we decided that the Plan does not have to 
pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) provided 
September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift for the enrollee. 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift for the enrollee.