Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the BRCA genetic testing rendered on August 30, 2021 to November 
25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services were not medically necessary. 
 
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 these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee has a history of right breast 
invasive ductal carcinoma and ductal carcinoma in situ (DCIS) diagnosed at age 69 and a sister with breast 
cancer diagnosed at age 50. She had cancer genetic counseling with three generation pedigree obtained. The 
criteria for coverage of the multigene panel are met. The testing was reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the BRCA genetic testing rendered on August 30, 2021 to November 25, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the complete series x-ray (D0210), scaling and 
root planing (D4342 x 2), localized delivery of antimicrobial agents (D4381 x 2), unlisted periodontal 
procedure (D4999 x 2), and unlisted adjunctive procedures (D9999 x 2) provided on March 30, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you should be reimbursed for these 
services. The Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series x-ray, scaling and 
root planing, localized delivery of antimicrobial agents, unlisted periodontal procedure, and unlisted adjunctive 
procedures are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to reimburse you for the complete series x-ray (D0210), scaling and root planing (D4342 x 2), localized 
delivery of antimicrobial agents (D4381 x 2), unlisted periodontal procedure (D4999 x 2), and unlisted 
adjunctive procedures (D9999 x 2) provided on March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper eyelid surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan does not cover services not considered medically reasonable or necessary under 
any condition. 
 
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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the enrollee's dermatochalasis is sufficiently low to produce 
a visually-significant field restriction. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve upper eyelid surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1845) and sleeve (CPT 
code L2397). 
 
You asked the Plan to pre-approve the orthosis and sleeve. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says the documentation indicates services are not 
necessary for treatment of the enrollees 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 the orthosis and sleeve. Our physician 
reviewer found the enrollee has not had recent surgery or a recent injury. The documentation does not support 
that the joint is unstable or that there is joint laxity. The requested knee orthosis is not 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 orthosis and sleeve have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the knee orthosis (CPT code L1845) and sleeve (CPT code L2397).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on November 8, 
2021. 
 You asked the Plan to pay for the services provided. You say that subarachnoid opioids are very effective. The 
Plan denied your request. The Plan says the records do not support the medical necessity of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that CPT code 62320 is not supported in the medical record. The 
records in the case file do not show that they were provided on the date of service at issue. Based on this 
information, we decided that Medicare rules for coverage of have not been met. Therefore, we decided that the 
Plan does not have to pay for the pain management services provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the fundus photography provided during a routine eye 
exam on January 7, 2022. 
 
You asked the Plan to hold you harmless for the fundus photography. You say that your doctor told you this 
was necessary, and you were not told it would not be covered. The Plan denied your request. The Plan says that 
this was denied correctly as it is noncovered per your contract. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided with the fundus photography by a contract provider. The file does not show that the Plan or 
the provider gave notice that the fundus photography would not be covered. The EOC does not specifically list 
this service as covered with an eye exam, but it also does not exclude this from coverage or state that only the 
services mentioned are covered. Under Medicare rules, this means the fundus photography is considered 
approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the fundus photography 
provided during a routine eye exam on January 7, 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's care can be safely provided at a less intensive setting of 
care. 
 
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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. 
The enrollees care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says additional 
visits are not medically reasonable and 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 additional 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 documentation does not reveal that the patient requires the unique 
skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. Our reviewer also found 
that the requested services are not part of a maintenance program, and the specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the 
patient's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 7 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
(99072) provided on September 27, 2021. 
 
You asked the Plan to pay for the additional supplies, materials, and clinical staff time (99072). You say that 
the medical records required to reprocess the denied claim are attached. The Plan denied your request. The Plan 
says procedure code 99350 has been paid and procedure code 99072 remains denied as bundled services are not 
eligible for separate reimbursement.  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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the additional supplies, materials, and clinical staff time (99072) have not been met. Therefore, we decided 
that the Plan does not have to pay for the additional supplies, materials, and clinical staff time (99072) provided 
on September 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of intact breast implant (CPT code 19328), 
peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents) (CPT code 
19371) and removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) (CPT code 
19330). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says removal of the intact right breast implant and related procedures is not medically 
necessary because there is no evidence of infection, broken or failed implant, or painful capsular contracture 
with disfigurement. 
 
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 services. Our physician reviewer 
found the Medicare rules in LCD L37020 state that removal of breast implants is considered medically 
necessary for any one or more of the following conditions: Broken or failed implant, Infection, Implant 
extrusion, Siliconoma or granuloma, Interference with diagnosis of breast cancer, Painful capsular contracture with disfigurement. Removal of the intact right breast implant and related procedures are not medically 
necessary per Medicare rules because there is no evidence of infection, broken or failed implant, or painful 
capsular contracture with disfigurement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal of intact breast implant (CPT code 19328), peri-implant capsulectomy, breast, 
complete, including removal of all intracapsular contents) (CPT code 19371) and removal of ruptured breast 
implant, including implant contents (eg, saline, silicone gel) (CPT code 19330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, monaural, behind the ear (V5257) 
provided October 8, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware that the Plan would not cover 
hearing aids. The Plan denied your request. The Plan says hearing aids are not covered under your benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aid, 
digital, monaural, behind the ear (V5257) provided October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630) provided on January 4, 2022. 
 
You asked the Plan to pay for the drugs or medicaments. You say that you had gone almost two years without a 
dental checkup because the Plan has not been able to keep an in-network provider in your area. The Plan 
denied your request. The Plan says this service is not a covered expense under your dental plan. 
 
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 pay for the drugs 
or medicaments dispensed in the office for home use (D9630) provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99225) provided November 10, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says original Medicare is liable for payment for these services. 
 
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 physician services (99225) provided November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual exam provided on December 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that you understood that you could pay out of 
pocket and then file for reimbursement. The Plan denied your request. The Plan says the provider no longer 
accepts Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the annual 
exam provided on December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator. 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that the enrollee is in need of a bone 
stimulator to help to further heal her fusions. You say that the alternative would have to be a complete revision 
of her triple arthrodesis and midfoot fusion which they are trying to avoid. The Plan denied your request. The 
Plan says the guidelines for coverage have not been met because it has been less than nine months since the 
enrollee's last surgery. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.  
 
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 osteogenesis stimulator. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records show 
that the enrollee has had foot surgery and that 9 months have not passed since the surgery. Not enough time has 
passed to establish the diagnosis of nonunion. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, of diagnostic or therapeutic substances (anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided November 1, 2021. 
 
You asked the Plan to pay for the injection services. You say that you are appealing the Plan's decision to deny 
payment. The Plan denied your request. The Plan says there is insufficient documentation to support the 
medical necessity of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection services have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. the records provided are 
undated and unsigned. Therefore, we decided that the Plan does not have to pay for injection, of diagnostic or 
therapeutic substances (anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic 
substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic 
(62320) provided November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level 
(CPT code(s): 64484 and 64483). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 services. Our physician reviewer 
found the most recent lumbar spine magnetic resonance imaging (MRI) revealed no foraminal stenosis or 
central spinal stenosis. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, each additional level (CPT code(s): 64484 and 64483).