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

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on June 22, 2021. 
 
You asked the Plan to pay for the therapeutic activities. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation does not support this 
service as billed. 
 
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. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the therapeutic activities (97530) 
provided on June 22, 2021, have been met. In this case, medical records have not been provided. Without these 
records, it is impossible to corroborate the services as they were billed. Therefore, we decided that the Plan 
does not have to pay for the therapeutic activities (97530) provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy using Lutathera. 
 
You asked the Plan to pre-approve the requested services. You say that Lutathera improved survival outcomes 
and quality of life. The Plan denied your request. The Plan says that it has not been shown that the enrollee's 
cancer has responded well to this treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that Lutathera (lutetium Lu-177-labelled somatostatin analogue peptide) is a radioactive analog 
to somatostatin that is used to treat to neuroendocrine tumors. It is unclear what the basis for denial is in this 
case. Perhaps being that he is not currently on octreotide or lanreotide, although the records clearly demonstrate 
that these drugs were not tolerated by the enrollee. Based upon the other criteria outlined by the National 
Comprehensive Cancer Network (NCCN) guidelines, and the enrollees case meeting these criteria, it is 
reasonable that the treatment would be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve radiation therapy using Lutathera.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
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 Botox. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Dysport or Xeomin before they will approve the requested drug, Botox. Based on 
the medical records provided, there is no indication that the enrollee has tried and failed the required drugs. 
There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox (J0585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from May 
12, 2022, forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee is at high risk 
of suicide if discharged prematurely. The Plan denied your request. The Plan says under Medicare guidelines, 
the request is not medically necessary because the records received show the enrollees condition has improved 
and he is no longer a threat to himself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continued inpatient psychiatric care. 
Our reviewer says that a continued inpatient psychiatric admission from May 12, 2022, forward is not 
medically necessary. Our physician reviewer found that the enrollee did not require inpatient mental health 
treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not 
have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
It appears that the services were supervised and evaluated by a physician. Based upon review of the records 
provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment 
from May 12, 2022, forward and could have been treated in a lesser restrictive setting as he was not showing 
any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive 
behaviors while being cooperative and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continued inpatient psychiatric admission from May 12, 2022, 
forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
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 these are not covered items. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 A6533.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve massage therapy. You say that massage therapy would help with your right 
scapula pain. The Plan denied your request. The Plan says massage therapy is not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronary atherectomy (92934) provided on August 11, 
2021. 
 
You asked the Plan to pay for the coronary atherectomy (92934). You say that CPT code 92934 is for each 
additional branch of a major coronary artery for a stent as there were two stents put in. You say that you 
attached the operative report for review and payment of CPT code 92934. The Plan denied your request. The 
Plan says bundled services are not eligible for separate payment. 
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 CPT code 92934 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 92934 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the coronary atherectomy (92934) have not been met. Therefore, we decided that the Plan does not have to 
pay for the coronary atherectomy (92934) provided on August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should require only short-
term additional acute care services that can be safely administered at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer may be considered when treatment has 
completed. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the soft tissue of the neck 
(70491). 
 
You asked the Plan to pre-approve a CT scan of the neck. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says that medical necessity rules for the requested 
service have not been met. 
 
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 a CT scan of the neck. Our reviewer 
says that the requested service is medically reasonable and necessary in this case. Our physician reviewer found 
that the presence of a palpable enlarged lymph node or other mass other than thyroid origin is a valid indication 
for a CT scan of the neck. While ultrasound may be of some use, that technique does not allow for evaluation 
of the floor of the mouth or upper airway, the common sites of primary tumors in the neck. A CT scan would 
allow such analysis. 
 
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 CT scan of the neck have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomography (CT) scan of the soft tissue of the neck (70491).  
 
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 an additional amount for the inpatient hospital care provided 
from September 23, 2020, to September 27, 2020. 
 
You asked the Plan to pay an additional amount for the inpatient care. You say that the billing of the primary 
diagnosis code, A41.9, is supported. The Plan denied your request. The Plan says the billing of the primary 
diagnosis code, A41.9, is not supported. 
 
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 primary diagnosis code, A41.9, sepsis, unspecified 
organism. 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 an additional amount for the inpatient 
care. Our reviewer says that the billing of primary diagnosis code, A41.9, sepsis, unspecified organism, is not 
supported. Our physician reviewer found the provided documentation does not indicate there was any clinical 
evidence of sepsis.  
 
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 
an additional amount for the inpatient hospital care provided from September 23, 2020, to September 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on May 4, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the limited clinical information in the case file does not support that cardiac risk assessment genetic screening testing was medically reasonable and necessary for the enrollee in this case. The documentation does 
not support that the testing was a standard of medical practice for the diagnosis or treatment of the enrollee's 
condition or to improve the function of a malformed body member. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve COVID testing kits. 
 
You asked the Plan to pre-approve the COVID testing kits. You say that you found information on a website 
that said health insurance companies were required to reimburse their members or COVID test kits. You say 
that you are being penalized for trying to do the right thing and follow the rules set in place. You say that other 
people who refuse to follow preventive measures end up in the hospital and require full medical care costing 
thousands of dollars to the taxpayers or health insurance companies. You say that you feel you are entitled to 
reimbursement for the COVID test kits you purchased. The Plan denied your request. The Plan says Medicare 
rules do not allow coverage for OTC items. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the COVID 
testing kits are an OTC item. Therefore, we decided that the Plan does not have to pre-approve COVID testing 
kits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammography (77067) provided on November 
11, 2021 
 
You asked the Plan to pay for the screening mammography. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the submitted documentation supports 
one unit of CPT code 77067 which was already processed and paid. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the screening mammography (77067) 
provided on November 11, 2021 have been met. Specifically, the documentation submitted shows that the Plan 
processed and paid for one unit of CPT code 77067 for the billed date of service. The records do not indicate 
that more than one unit of CPT code 77067 was rendered on the billed date of service.. Therefore, we decided 
that the Plan does not have to pay for the screening mammography (77067) provided on November 11, 2021
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous device, lumbar 
single level (22867). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the type of service requested by your doctor is not supported 
because research has not found it to be helpful for your condition or for what is causing your pain. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for your medical condition. Our physician reviewer 
found that your condition does not meet criteria for coverage of these services. 
 
 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 the insertion of interlaminar/interspinous device, lumbar single level (22867).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy PT visits. 
 
You asked the Plan to pre-approve 10 PT visits. You say that the additional visits are medically necessary. The 
Plan denied your request. The Plan says the additional PT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 10 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided documentation indicates improvement in pain and 
function. The reviewer found that the 20 previously approved visits would be reasonable to come up with a 
stable home exercise plan with range of motion exercises, stretching, flexibility training, core strength and 
modality use (documented goals). The reviewer also found there is no documented reason for an additional 
skilled therapy need or for treatment that would require a skilled therapist to implement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional physical therapy PT visits.