Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 28, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery did not include an order number or details to corroborate the delivery ticket submitted. Of note, the 
proof of delivery is not itemized to indicate the specific supplies. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted, and the proof of delivery is not itemized to indicate the 
specific supplies. However, the submitted documentation does contain an itemized packing slip dated 
September 28, 2022, with the same tracking number as the delivery ticket dated September 30, 2022. As the 
documentation supports that the items in question were delivered, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the electrical stimulator supplies provided on September 28, 
2022.  
 
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 pay for inpatient hospital services provided on April 21, 2021, to 
April 25, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 I21.A1, described as myocardial 
infarction due to demand ischemia, myocardial infarction secondary to ischemic imbalance. 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 documentation does not support the billed code. Our physician reviewer found that the 
enrollee is a 62-year-old male who presented to the hospital with weakness, nausea, vomiting, and fever 
following COVID-19 vaccination. He was noted to be hypotensive and orthostatic requiring fluids. 
Electrocardiogram normal. Echocardiogram showed Grade II diastolic dysfunction with normal ventricular 
systolic function. Inpatient hospital care billed with code I21.A1. However, the enrollee did not have any 
symptoms of chest pain, or test result findings to support the billed code.  
 
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 on April 21, 2021, to April 25, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (97597) provided on October 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment is 
included in the global surgery payment for code 28415. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that payment for code 97597 is included in the global surgery 
payment for code 28415. However, the Plan has not provided documentation showing that code 28415 was 
billed an paid in the 90 day prior to the date of service in question. Without supporting documentation, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (97597) 
provided on October 3, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oscillating bed. 
 
You asked the Plan to pre-approve an oscillating bed. You say that your provider recommended an oscillating 
bed to elevate you. The Plan denied your request. The Plan says an oscillating bed does not meet the definition 
of Durable Medical Equipment (DME). 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) is defined as 
equipment which is appropriate for use in a patients home. 
 
The requested item is not appropriate for home use. Therefore, we decided that the Plan does not have to pre-
approve an oscillating bed.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper partial denture-flexible base (including retentive/clasping 
materials, rests, and teeth) (D5225) and a lower partial denture-flexible base (including retentive/clasping 
materials, rests, and teeth) (D5226). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that your request exceeds the allowable benefit for these 
items at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan contract states that the dental benefit includes coverage for 
dentures once every five years. The Plan has stated that your request exceeds the allowable benefit for these 
items as you previously received dentures on September 19, 2018. However, the Plan has not provided 
substantiative evidence that demonstrates these items were provided to you on this day or that they were paid 
for by the Plan. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, 
we decided that the Plan has to pre-approve an upper partial denture-flexible base (including retentive/clasping 
materials, rests, and teeth) (D5225) and a lower partial denture-flexible base (including retentive/clasping 
materials, rests, and teeth) (D5226).  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires additional therapy to regain 
strength, the IRF is equipped to handle their medical conditions and help return their prior level of function. 
The Plan denied your request. The Plan says the request 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 pre-approve special supplemental benefit for the chronically ill 
(SSBCI) services. 
 
You asked the Plan to pre-approve the SSBCI services. You say that the records provided support the need for 
the services in dispute. The Plan denied your request. The Plan says there is no documentation that the enrollee 
meets the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the provided documentation did not 
sufficiently support medical necessity. Although the enrollee has many chronic, stable conditions being 
managed appropriately by the treating physician, the enrollee does not have an active diagnosis for one or more 
qualifying comorbid and medically complex conditions. The enrollees conditions are not life-threatening or 
significantly limiting the overall health or function of the enrollee. The enrollee does not require intensive care 
management and is not at a high risk for hospitalization based on the provided documentation.   
We looked at this physicians review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SSBCI services have not been met. Specifically, we have confirmed that 
you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that 
the Plan does not have to pre-approve special supplemental benefit for the chronically ill (SSBCI) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service September 
10, 2022. 
 You asked the Plan to pay for procedure code 76775. You say that the claim is billed correctly and should be 
paid The Plan denied your request. The Plan says payment for code 76775 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 76775 
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 76775 billed for date of service September 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service November 
18, 2022. 
 
You asked the Plan to pay for procedure code 88305. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says payment for code 88305 is bundled into payment for code 17311.  
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 88305 
is a column II code to column I code 17311. 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 88305 billed for date of service November 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (77387 x15, 77525 x15, G6002 
x15, 77523 x15). 
 
You asked the Plan to pre-approve proton beam therapy. You say that the requested therapy is medically 
necessary. The Plan denied your request. The Plan says there is no current research showing that the enrollee's 
type of cancer responds better to the requested type of treatment than the type of treatment the Plan can 
approve. 
 
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 Proton Beam Therapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found proton therapy is not an accepted standard for the treatment of oligometastatic 
disease or (as is the case for this enrollee) oligoprogressive disease. There are no consensus guidelines or 
literature provided to support the need for proton therapy in this enrollee. Proton therapy can be considered 
medically necessary when justified with quantitative dosimetric information that shows a clinically meaningful 
reduction in radiation dose exposure of normal tissues.  In order for toxicity risks to be reduced, there should be 
a clinically significant reduction in dose to critical structures, with an evidence basis of benefit with dose 
reduction. Generally, for the treatment of oligometastases or oligoprogression, there is no indication for proton 
therapy aside from exceptional circumstances, documented with a plausible dosimetric benefit. SBRT or 
hypofractionated radiotherapy can be considered with non-proton-based treatment which would be the standard 
of care. The LCD criteria are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Proton Beam Therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77387 x15, 77525 x15, G6002 x15, 77523 x15).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for BCR/ABL1 testing (81206) and molecular pathology procedure; 
physician interpretation and report (G0452) provided February 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please find the attached medical records and 
clinicals along with the waiver of liability. The Plan denied your request. The Plan says that the information 
requested from the billing/rendering provider was not provided or not provided timely or was 
insufficient/incomplete. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found BCR-ABL quantitative testing is a standard of care in monitoring patients being treated with 
chronic myelogenous leukemia. This enrollee is undergoing active treatment for chronic myelogenous 
leukemia. 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 pay for BCR-ABL1 testing (81206) and molecular pathology procedure; physician interpretation and report 
(G0452) provided February 16, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a skin biopsy and clinic visit provided on 
June 20, 2022. 
 
You asked the Plan to waive the cost share for the biopsy and clinic visit. You say that you thought this would 
be totally covered. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to certain items and services. The 
Plan deductible applies to outpatient hospital services. The Plan contract also says you must pay a $350 
copayment after your deductible is met which applies to each Medicare-covered outpatient surgery.  
 
You have been asked to pay $136.14 towards your deductible. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible which applies to outpatient hospital services. This 
cost sharing is a contractual obligation that had not been met at the time the clinic visit was received on June 
20, 2022. 
 You have also been asked to pay a $341.89 copayment for the outpatient hospital services, which is less than 
the standard $350 copayment. You have been asked to pay a total of $478.03 ($136.14 deductible + $341.89 
copayment = $478.03). These items/services fall within the outpatient hospital services 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, the Plan does 
not have to waive the cost share for the skin biopsy and clinic visit provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (20611, J7324) provided on August 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was not 
billed appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for codes 20611 and J7324 is not supported in the medical record. Specifically, codes 
20611-LT and J7324-LT were billed with a diagnosis pointer to diagnosis code M25.561, and codes 20611-RT 
and J7324-RT were billed with a diagnosis pointer to diagnosis code M25.562. It is inappropriate to bill a left-
sided procedure with a right-sided diagnosis code, and a right-sided procedure with a left-sided diagnosis code. 
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 the services (20611, J7324) provided on August 
24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional chiropractic manipulative treatments and  
3 office visits. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested services. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 
you do not meet criteria for coverage of the requested services. Our physician reviewer found that in this case, 
the record indicates that you have neck pain, shoulder pain, and low back pain. The record indicates that three 
visits have been approved. The record provided is insufficient to establish that the additional visits requested 
are for active care or that the services are medically necessary. The elements of the coverage criteria are not 
satisfied. The elements required by the supplemental benefit are not satisfied. The requested services are not 
recommended. 
 
We looked at this physician's review, the file, and both Medicare and the Plans rules. Based on this 
information, we decided that both Medicare and the Plans rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve 3 additional chiropractic manipulative 
treatments and 3 office visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label, 
not medically accepted use. 
 
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 Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Keytruda is not FDA-approved for the enrollees diagnosis. The use is not supported by one of 
the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Keytruda (J9271).