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

 
We decided that the Plan does not have to pay for the psychotherapy visit (90837) provided on November 23, 
2021. 
 
You asked the Plan to pay for the psychotherapy visit. You say that the provider is in-network so this should be 
covered. The Plan denied your request. The Plan says the provider is in-network, however an LMHP provider 
is not covered for mental health services. 
 
The Plan must follow Medicare rules. Medicare rules say that a LMHP is not an eligible professional for 
mental health services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy visit have not been met. Specifically, a Licensed Mental Health Professional is 
not a provider that is eligible to receive Medicare payment. Therefore, we decided that the Plan does not have 
to pay for the psychotherapy visit (90837) provided on November 23, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for your power wheelchair. 
 
You asked the Plan to pre-approve repairs for your power wheelchair. 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. Medicare rules say that repairs to equipment which a beneficiary owns 
are covered when necessary to make the equipment serviceable. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of repairs for your power wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repairs for your power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle brace provided on March 3, 2022. 
 
You asked the Plan to pay for the ankle brace. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the medical records do not support the need for this 
item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, there is nothing in the medical records provided related to any condition affecting the 
patient's ankle.  There is no documentation of why this item may have been ordered for the patient in the medical records. Therefore, we decided that the Plan does not have to pay for the ankle brace provided on 
March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical collar provided on December 21, 2021. 
 
You asked the Plan to pay for the cervical collar. You say that you have submitted records to support payment. 
The Plan denied your request. The Plan says the records do not support the need for this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, there is nothing in the patient's medical records related to a neck or cervical condition 
for which a cervical collar would have been ordered. None of the patient's diagnoses documented in the 
medical record have anything to do with a neck or cervical issue. Therefore, we decided that the Plan does not 
have to pay for the cervical collar provided on December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Artoss NanoBone allograft. 
 
You asked the Plan to pre-approve Artoss NanoBone allograft. 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 Artoss NanoBone allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Altros Bone allograft remains experimental. More research is needed. Iliac 
crest autograft is the gold standard. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Artoss NanoBone allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Artoss NanoBone allograft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
  You asked the Plan to pre-approve Evenity. You say that the provider informed you that you had significant 
amount of bone loss. The Plan denied your request. The Plan says you have not tried any of the preferred 
agents and do not have any contraindications to the preferred products. 
 
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 Evenity. Our reviewer says that there is 
no contraindication to Forteo which is the preferred step therapy next drug.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the primary insurance carrier must be 
billed first before the Plan is obligated to pay as the secondary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has indicated that they called the provider and directed them to bill the primary insurer. As the secondary insurer, the Plan cannot 
be held responsible for the laboratory services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 18, 
2022.  
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says in addition to single gene testing, panels that include the FANCC genes are statutorily 
excluded service. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that per the National Comprehensive Cancer Network (NCCN) guidelines at present, several targeted 
therapeutic agents, trastuzumab, pembrolizumab/nivolumab, and entrectinib/larotrectinib, have been approved 
by the FDA for use in esophageal and esophagogastric junction (EGJ) cancers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on January 18, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says there are no complex medical or intensive rehabilitation needs, requiring supervision by 
a rehabilitation physician and an intensive and coordinated interdisciplinary team in a resource intensive 
inpatient hospital environment. 
 
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 based on the medical records provided, the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patients medical conditions appear stable on outpatient medications with 
no issues that appear to require a physicians evaluation three or more times per week. The patient does require 
physical therapy and occupational therapy services, but the medical records provided do not clarify why the 
patient requires an intensive inpatient rehabilitation therapy program. The 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 patient. There is concern that the patient will not be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to her reported poor endurance and dyspnea with activity as well as her refusals to 
participate with therapy in the acute hospital. The records do not clarify that treatment at the skilled nursing 
facility level is not 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy with moderate sedation services provided to 
the enrollee on November 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is  
 
CPT 45378: 
 
Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when 
performed (separate procedure) 
 
 
 CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
CPT 99153: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 45378, the 
procedure report describes a colonoscopy to sigmoid. In this case, an appropriate modifier should be appended 
for service documented, as documentation does not meet criteria for this procedure code. In terms of CPT 
99152, the documentation does not include documentation of an independent trained observer to assist in the 
monitoring of the patient's level of consciousness and physiological status (per CPT code description). 
Healthcare plan denied payment for unbundled service from esophagogastroduodenoscopy (EGD). No 
documentation was found that moderate sedation is inclusive to this procedure. In terms of CPT 99153, this 
procedure is not considered a professional service. Therefore, in this case, modifier TC 26 would not be 
reported for this procedure code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a colonoscopy with moderate sedation services provided to the enrollee on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on March 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that the wound care supplies are a separately 
billable expense that does not require separate authorization. The Plan denied your request. The Plan says no 
prior authorization was obtained. 
 
 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 
wound care supplies. We found no exception that would require the Plan to pay for the wound care supplies. 
The records provided for review do not show that the wound care supplies were urgent or emergent. Therefore, 
we decided that the Plan does not have to pay for the wound care supplies provided on March 8, 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 Velocity VR2, power wheelchair, group 3 standard, 
single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the power wheelchair is medically 
necessary due to immobility and is a significant risk for skin breakdown and injury due to falls with high fall 
and transfer risk. The Plan denied your request. The Plan says the requested power wheelchair does not meet 
criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 power wheelchair. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is documentation that the 
enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living 
such as toileting, feeding, grooming and bathing in customary locations within the home. There is no 
documentation that the group 3 power wheelchair with a single power option at issue in this case meets 
Medicare criteria. Provided records do not document that the enrollee is at high risk for skin breakdown, uses a 
catheter for bladder self-catheterization or has increased muscle tone or spasticity to meet criteria for the power 
tilt feature and thus the single power option. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Velocity VR2, power wheelchair, group 3 standard, single power option, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds (K0856).
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 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 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 your functional status does require intensive rehabilitation. These are not complex or 
intensive rehabilitation needs. You have chronic dialysis; her dialysis routine and chronic renal failure management are well-established. You do not have complex rehabilitation needs requiring frequent physiatry 
oversight. Your medical needs are post-acute and do not inhibit or complicate your post acute rehabilitation 
needs. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi for the enrollee. 
 
You asked the Plan to pre-approve Imfinzi. You say that this is medically necessary. The Plan denied your 
request. The Plan says that medical studies haven't proven that this drug is helpful when you've tried but not 
had a positive response to another anti-PD1 drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Imfinzi. Our reviewer says that Imfinzi 
is not medically reasonable and necessary. Imfinzi is not FDA-approved for the enrollees diagnosis. Imfinzi is 
a programmed death-ligand 1 (PD-L1) blocking antibody indicated for the treatment of adult patients with 
unresectable, Stage III non-small cell lung cancer (NSCLC) whose disease has not progressed following 
concurrent platinum-based chemotherapy and radiation therapy. The documentation in this case supports that 
there has been progression of disease following concurrent platinum-based chemotherapy and radiation 
therapy. The use of Imfinzi is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of Imfinzi. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi for the enrollee.