Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety 
and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and treatment to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal.   
We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that 
the Plan does not have to pre-approve office visits and treatment to be rendered by the out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
November 29, 2021. 
 
  You asked the Plan to pay for the moderate sedation services (99153). You say that the medical claim was 
billed using the correct place of service and the medical records substantiate the place of service that 
performed. You say that the claim should be reconsidered, and payment issued. The Plan denied your request. 
The Plan says CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital 
outpatient department. 
 
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 code 99153 is 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 find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on November 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 50mg Toprol XL tablets. 
 
You asked the Plan to pre-approve the Toprol XL tablets. You say that you would like reconsideration because 
the requested drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered 
under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 50mg Toprol XL tablets.  
 Benefits for the Toprol XL tablets 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 the anesthesia for nerve blocks and injections (01992) 
provided on November 19, 2021. 
 
You asked the Plan to pay for the anesthesia for nerve blocks and injections (01992). You say that you have 
severe spinal stenosis, and this doctor is essential to your wellbeing. You say that you were referred to this 
doctor by your neurosurgeon and you are submitting the unpaid balance of $135.50. The Plan denied your 
request. The Plan says a modifier cannot bypass this code edit.  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 01992 
is a column II code to column I code 64493. This claim cannot be billed with a 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 anesthesia for nerve blocks and injections (01992) provided on November 19, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 1, 
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 an appropriate modifier was not 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, we have confirmed that code 93010 
is a column II code to column I code 36556. 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 imaging services provided to the enrollee on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide an office visit to an OON provider. 
 
You asked the Plan to provide an office visit. You say that the OON provider can do a better surgery than the 
in-network providers. The Plan denied your request. The Plan says there are in-network providers that can 
render a similar service. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 provide an office visit. Our reviewer says that the 
enrollee does not meet the Medicare criteria for treatment with an out-of-network provider. Our physician 
reviewer found the Plan denial is justified. There is nothing in the available records to support the necessity of 
seeing an OON provider, and the Plan-provided in-network care meets standard-of-care appropriate to your 
treatment and conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not 
have to provide an office visit to an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on 
November 9, 2021. 
 
You asked the Plan to pay for the office visit. You say that this provider is a covered provider and you have 
attached the documentation showing her board certification, state license information and Medicare welcome 
letter. You say that the documentation should be reviewed, and the claim reprocessed accordingly. The Plan 
denied your request. The Plan says this provider is not a network provider, and the services were not approved 
in advance. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network 
provider on November 9, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve intravenous zoledronic acid 5mg once per year. 
 
You asked the Plan to pre-approve the requested 5mg yearly dose of zoledronic acid. You say that this should 
be approved. The Plan denied your request. The Plan says that the requested dosage is not supported. Only 4mg 
per year is medically necessary to prevent aromatase-inhibitor osteoporosis. 
 
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 the requested 5mg yearly dose of 
zoledronic acid. Our reviewer says that the requested treatment is medically reasonable and necessary. Our 
physician reviewer found the enrollee is a female with a history of breast cancer currently treated with 
Arimidex. Recent testing showed osteopenia, with a request for 5mg zoledronic acid, yearly. This is supported 
by the findings of Shapiro CL, et al., in the study "Management of osteoporosis in survivors of adult cancers 
with nonmetastatic disease: ASCO clinical practice guideline.", published in the Journal of Clinical Oncology. 
The requested treatment is reasonable and 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 requested 5mg yearly dose of zoledronic acid have been met. Therefore, we 
decided that the Plan has to pre-approve intravenous zoledronic acid 5mg once per year.  
 
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 pay for the pneumatic compression device (code E0675) and 
accessory (code E0673) provided on July 28, 2021. 
 
You asked the Plan to pay for the pneumatic compression device and accessory. You say that these items were 
used for the prevention of deep vein thrombosis, venous thromboembolism, and pulmonary embolism. The 
Plan denied your request. The Plan says Medicare does not cover this item. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices coded as E0675 
is coverable only for the treatment of peripheral artery disease.  This item is considered not reasonable and 
necessary for other conditions. Accessories are only covered when the pneumatic compression device itself is 
covered. In this case, the items were not provided to treat peripheral artery disease.  Rather, they were used for 
blood clot prevention.  Although this may be medically appropriate, neither Medicare nor the Plan covers these 
items for this reason. Based on this information, we decided that Medicare rules for coverage of the pneumatic 
compression device and accessory have not been met. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (code E0675) and accessory (code E0673) provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EEG (95822) provided on April 21, 2021. 
  You asked the Plan to pay for the EEG (95822). You say that the provider performs this procedure to measure 
the electrical activity of the brain and the charges are appropriate for the intensity of the medical services 
provided. You say that the payment rendered is not comparable to the rates charged and you should be 
reimbursed 100% of the billed charges. The Plan denied your request. The Plan says procedure codes 51785, 
51785, 95861 and 95861 were overturned. The Plan also says that CPT code 95822 remains denied as an 
appropriate modifier was not 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, we have confirmed that code 95822 
is a column II code to column I code 51785. 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 EEG (95822) provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (code E0675) and 
accessory (code E0673) provided on September 17, 2021. 
 
You asked the Plan to pay for the pneumatic compression device and accessory. You say that these items were 
used for the prevention of deep vein thrombosis, venous thromboembolism, and pulmonary embolism The Plan 
denied your request. The Plan says Medicare does not cover these items. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices coded as E0675 
is coverable only for the treatment of peripheral artery disease.  This item is considered not reasonable and 
necessary for other conditions. Accessories are only covered when the pneumatic compression device itself is 
covered. In this case, the items were not provided to treat peripheral artery disease.  Rather, they were used for 
blood clot prevention.  Although this may be medically appropriate, neither Medicare nor the Plan covers these 
items for this reason. Based on this information, we decided that Medicare rules for coverage of the pneumatic 
compression device and accessory have not been met. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (code E0675) and accessory (code E0673) provided on September 17, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient medical services provided on September 11, 2021. 
 
You asked the Plan to pay for inpatient medical services. You say that this claim should be paid. The Plan 
denied your request. The Plan says the patient was enrolled in hospice on the date of service in question, so 
Original Medicare, not the Plan, is responsible for the claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for inpatient medical services provided on September 11, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) a special kind of picture of 
your hip, knee or ankle. 
 
You asked the Plan to pre-approve an MRI a special kind of picture of your hip, knee or ankle. You say that the 
services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI a special kind of picture of 
your hip, knee or ankle. Our reviewer says that the services are medically necessary. Our physician reviewer 
found the enrollee completed a course of physical therapy without improvement. Thus, the enrollee qualifies 
for the requested MRI of the right knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI a special kind of picture of your hip, knee or ankle have been met. 
Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) a special kind of 
picture of your hip, knee or ankle.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided July 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided July 19, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While you may benefit 
from physical therapy, and occupational therapy, your rehab can be safely provided at a lower intensity and 
alternate setting such as in a skilled nursing facility or in-home with 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 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 (88305) provided on September 13, 
2021. 
 
You asked the Plan to pay for code 88305. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, the records indicate that the 
member was an outpatient on the billed date of service. Payment for CPT code 88305 is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (88305) provided on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided August 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample 
was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services 
(83789) provided August 4, 2021.