Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001), also 
known as US-IGRT. 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that there are six decisions 
from a CMS qualified independent contractor clearly stating that IGRT is medically necessary and covered by 
Medicare. Please review, reprocess, and approve according to the contract as a medical necessity. The Plan 
denied your request. The Plan says the guidelines state RT dose decisions are based on tumor diameter for 
local, low-risk disease, not ultrasound determined depth. Neither NCCN nor other guidelines recommend US 
imaging for staging, diagnosis, or to assess treatment response. The request does not meet the Medicare or 
health plan coverage criteria. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found IGRT is a means to improve set-up accuracy. Specifically, IGRT 
allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be 
reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used 
when critical structures are abutting or in close proximity to the target that is being treated to high doses. This 
situation does not apply to this enrollee for which the target lesion can be seen on the skin to assist in daily set 
up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. 
Certainly, using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is 
FDA approved for use with ultrasound though that in and of itself does not mean that daily imaging is 
necessary but simply that the device was designed to incorporate this functionality. Therefore, to bill for daily 
simple simulations and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general) 
is not necessary. The decision is unfavorable as billing for daily IGRT which would not 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 ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001), also known as US-
IGRT.
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 for the enrollee to return to 
prior level of function. The Plan denied your request. The Plan says your medical condition requires further 
evaluation and treatment in the acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that enrollee's needs an LTACH level of care 
to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and the enrollee's needs can be met at the current hospital setting. 
 
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 that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
   
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the face. 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says the clinical records do not show the criteria for a repeat CT scan was 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 the CT scan. Our reviewer says that the 
CT scan of the face is not medically necessary. Our physician reviewer found that the enrollee has chronic 
sinusitis and reports daily headaches, sinus congestion, and ear congestion. Prior CT sinuses from December 5, 
2022, described bilateral lamina papyracea dehiscence, orbital fat bulging into ethmoid air cells, prominent 
maxillary sinus disease including layering fluid and mucosal thickening and osteo-meatal complex obstruction, 
multifocal ethmoid and frontoethmoidal opacities, and bilateral stylohyoid ligament ossification. Repeat CT 
scan of the head/brain was requested. However, it was not clear from the provided documentation whether 
symptoms or physical findings have changed significantly to reveal a red flag diagnosis to justify repeat 
advanced imaging of the head/sinus. The recent imaging should be sufficient to help decide ongoing treatment 
for this 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 the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the face.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service April 20, 
2022. 
 
You asked the Plan to pay for procedure code G0453. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code G0453 is bundled into payment for 
code 95957. 
 
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 G0453 
is a column II code to column I code 95957. 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 G0453 billed for date of service April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has serious life threatening acute 
medical problems that have left them at a functional status below their baseline. You say that the enrollee can 
benefit from an acute rehab to optimize their level of functioning prior to returning home. The Plan denied your 
request. The Plan says an IRF admission 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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression devices (E0675, E0673) 
provided on August 29, 2022. 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable 
medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
  The case record indicates that the items at issue in this appeal were for use outside of the home. Although these 
items may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pay for intermittent limb compression devices (E0675, E0673) provided 
on August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on September 09, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan. You say that you disagree 
with the copaymet. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for outpatient diagnostic tests/computed tomography (CT). 
 
You have been asked to pay a $300 copayment for computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests/computed tomography (CT) 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, we decided that the Plan does not have 
to waive the copayment for computed tomography (CT) scan provided on September 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4260). 
 
You asked the Plan to pay for the dental services. You say that you are on social security, and you cannot 
afford this. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan has agreed to pay $934. The enrollee is responsible for any additional charges due to your 
maximum dental allowance amount being met after the $934 is applied. Therefore, we decided that the Plan 
does not have to pay for osseous surgery (D4260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration in conjunction with periradicular surgery tooth #27 (D3431). 
 
You asked the Plan to pre-approve the biologic materials to aid in soft and osseous tissue regeneration in 
conjunction with periradicular surgery tooth #27 (D3431). You say that you would like to know if the service 
could be covered. The Plan denied your request. The Plan says this service is not covered under the benefit 
package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery tooth 
#27 (D3431).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker (33274). 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the service is medically necessary. The 
Plan denied your request. The Plan says there is no indication the member is enrolled in a CMS approved 
study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Specifically, there is no indication the member is enrolled 
in a CMS approved study. Therefore, we decided that the Plan does not have to pre-approve a leadless 
pacemaker (33274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a heavy-duty power wheelchair. 
 
You asked the Plan to pre-approve repairs to a heavy-duty power wheelchair. You say that everything has 
fallen off the chair including the pad that is on the side, the controls, the left side wobbles, both of the two new 
arm pads on each side need to be replaced, and the foot plate dropped all the way to the ground. The Plan 
denied your request. The Plan says there is not enough information in the records received to show a medical 
need for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
  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 repairs to a heavy-duty power 
wheelchair have been met. The documentation fails to indicate that the vendor has assessed if the requested 
repairs are needed for your current heavy duty power wheelchair. The record shows that the Plan attempted to 
contact you twice to discuss if you would be willing to have an evaluation scheduled to determine if repairs are 
needed, but each time, the phone was disconnected after the greeting. Also, no medical records were provided 
with this case. Therefore, we decided that the Plan does not have to pre-approve repairs to a heavy-duty power 
wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that medical records were provided. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy/gingivoplasty (D4210). 
 
You asked the Plan to pre-approve gingivectomy/gingivoplasty. You say that you would like pre-approval for 
these services. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingivectomy/gingivoplasty (D4210).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9375 billed for date of service September 
15, 2022, to September 28, 2022. 
 
You asked the Plan to pay for procedure code S9375. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9375 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9375 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code S9375 billed for date of service September 15, 2022, to September 28, 2022.
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 this is the most appropriate level of care 
for the enrollee to receive the services needed. The Plan denied your request. The Plan says the enrollee's care 
can be provided in the current inpatient hospital. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 6, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 6, 2022.