Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional PT visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The 
Plan denied your request. The Plan says additional PT is 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 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 additional requested therapy generally is accepted as specific and 
effective therapy for your condition status post hip replacement. You have had prior therapy and the 
documentation does not reveal that you require the unique skills of a professional therapist to safely and 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist. You have been instructed in a home exercise program for your hip. 
The documentation indicates your symptoms may be spine related. 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 your 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 additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external hyperthermia treatment depth 4 cm or less 
(77600) provided August 27, 2021. 
 
You asked the Plan to pay for the external hyperthermia treatment. You say that these are two distinct 
treatments in two separate sites and should be paid as such. The Plan denied your request. The Plan says the 
claim was billed with inappropriate modifier combination. 
 
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 77600 is external hyperthermia treatment depth 4 cm or 
less. 
 
We asked our coder 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 external hyperthermia treatment. Our reviewer says that 
CPT code 77600, 59, XU is not supported in the medically records. Our reviewer found the provider reported 2 modifiers for the same procedure code.  Procedures codes should not be reported with XU and 59 for the same 
procedure code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the external hyperthermia treatment have not been met. Therefore, we decided 
that the Plan does not have to pay for the external hyperthermia treatment depth 4 cm or less (77600) provided 
August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee reports significant pain. 
The Plan denied your request. The Plan says the injection is not reasonable or necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
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 the enrollee has chronic low back pain and fibromyalgia. She has tried physical therapy, a 
home exercise program, chiropractic therapy, heat/ice, and acupuncture. Her pain medications have included 
Lyrica, Gabapentin, and Voltaren. The physical exam does not include evidence of radiculopathy. There is no 
documentation of a recent MRI or CT scan. There is no documentation of an electromyography or nerve 
conduction study.  The request does not meet the coverage criteria. Therefore, the request is deemed not 
medically reasonable or 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural steroid injection.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you have been going to this provider and would like 
the visit to be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no referral from your primary care physician or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit provided on June 29, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99153) provided on September 16, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a 
practice expense (PE) only code and is not paid to the physician in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT 
code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99153) provided on September 18, 2020. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services (99153) provided on September 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dual-energy X-ray absorptiometry bone density study 
(77080) provided on August 17, 2021. 
 
You asked the Plan to pay for a dual-energy X-ray absorptiometry bone density study. You say that this was 
billed correctly. The Plan denied your request. The Plan says this is not supported by the billed diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that dual-energy x-ray absorptiometry (axial) tests are 
covered when coded with M81.0, M81.8, M81.6 or M94.9 as the International Classification of Diseases, 10th 
Revision, Clinical Modification (ICD-10-CM) diagnosis code.  
We looked at the file and Medicare rules. The dual-energy x-ray absorptiometry was billed with the ICD-10-
CM code Z13.820, encounter for screening for osteoporosis, which is not a covered diagnosis. Based on this 
information, we decided that Medicare rules for coverage of a dual-energy X-ray absorptiometry bone density 
study have not been met. Therefore, we decided that the Plan does not have to pay for a dual-energy X-ray 
absorptiometry bone density study (77080) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and unspecified preventive procedure, by report (D1999) provided December 21, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and unspecified preventative procedure. You say 
that you needed a new in-network dentist. The Plan denied your request. The Plan says you have exceeded the 
frequency limit for the comprehensive exam and the unspecified preventative procedure is not a covered 
service. 
 
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. The Plan covers the 
comprehensive oral exam once every three calendar years.  
 We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral 
exam was previously covered on August 20, 2020. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral exam has been exceeded. Though the Plan offers dental 
benefits in excess of Medicare coverage, the unspecified preventative procedure is not among those covered 
services. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new 
or established patient (D0150) and unspecified preventive procedure, by report (D1999) provided December 
21, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from October 22, 2021, through October 
29, 2021. 
 
You asked the Plan to pay for the home health services. You say that these claims are not episodic and paid 
monthly per visit. You say that the claims should be reprocessed accordingly. The Plan denied your request. 
The Plan says that we are maintaining the original decision to not pay as the claim is billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence or rationale to support 
their denial of this claim. It is the burden of the Health Plan to substantiate their denial with evidence. In this 
case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan 
has to pay for home health services provided from October 22, 2021, through October 29, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on September 7, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that POS 81 is correct for this service. The 
Plan denied your request. The Plan says the POS reported does not match the location where the sample was 
taken. 
 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 Guardant360 testing 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 the Guardant360 testing provided on September 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready 
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although 
further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent 
skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and 
effectively only on an inpatient basis. 
 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard injections. 
 
You asked the Plan to pre-approve Gammagard. You say that the requested drug is necessary. The Plan denied 
your request. The Plan says the requested drug is not approved by the FDA for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Gammagard. Our reviewer says that the 
requested Gammagard injections are not medically necessary. Our physician reviewer found that the requested 
use of Gammagard is not FDA-approved for the enrollees diagnosis. The reviewer found that the requested use 
is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal (see appendix for list of CMS-approved journals. Therefore, the reviewer found that requested 
drug is not medically reasonable or 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 Gammagard have not been met. Specifically, the file indicates that the 
requested drug is not approved by the Food and Drug Administration for the enrollee's diagnosis. Therefore, we 
decided that the Plan does not have to pre-approve Gammagard injections.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the complete multivitamin purchased on December 10, 2021. 
 
You asked the Plan to pay for the complete multivitamin. You say that the Plan states energy vitamins do not 
qualify but the label states this is a complete multivitamin for men. The Plan denied your request. The Plan 
says that the Mens Energy Complete Multivitamin is ineligible for reimbursement. Multivitamins are eligible, 
however vitamins with fruits and veggies and marked as energy are not eligible per eligibility guidelines. 
 
The rules say that Medicare does not pay for OTC items, but you have a Pick Your Perks program to cover 
eligible OTC items. The Plan says vitamins marked energy are not an eligible expense, but the Pick Your Perks 
Benefit guide says that multivitamins are covered. It does not clearly distinguish that energy complete 
multivitamins are not a covered type of multivitamin. Therefore, we decided that the Plan has to pay for the 
complete multivitamin purchased on December 10, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve out of area (OOA) dermatology services. 
 
You asked the Plan to pre-approve OOA dermatology services. You say that you went to an urgent care center 
while in Florida and they found possible skin cancer. You say that you want to get this taken care of while you 
are in Florida, since you will be there for another month after Easter. The Plan denied your request. The Plan 
says that there are dermatologists in the network who can treat the enrollee's clinical condition and there is no 
medical rationale for why they cannot travel back to the area for this treatment. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved 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 pre-approve OOA dermatology services. Our 
reviewer says that the criteria for coverage of OOA care have been met. Our physician reviewer found there is 
no evidence that the enrollee could have foreseen requiring the services prior to leaving the service area. The 
records show that the skin lesion was present for one month. The records indicate that the care being requested 
is medically necessary. The care being requested is medically necessary. It has not been established that it is 
medically reasonable to delay these services until the enrollee returns home, as she has a potential neoplasm. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OOA dermatology services have been met. Therefore, we decided that the Plan 
has to pre-approve out of area (OOA) dermatology services.  
 
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 pay for the hearing aid repair provided on July 27, 2021, through 
October 16, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that the items are medically necessary. The Plan denied 
your request. The Plan says these items were obtained through a non-Plan provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only up to two hearing aids a year when obtained through a Plan provider.  
 
 
 
 
 
 
 We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Specifically, you did not obtain this item through a Plan 
provider. This means the items are not covered. Therefore, we decided that the Plan does not have to pay for 
the hearing aid repair provided on July 27, 2021, through October 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on July 15, 2021. 
 
You asked the Plan to pay for the Tempus gene panel. You say that this is a medically necessary test that 
should be covered. The Plan denied your request. The Plan says Medicare only covers Food and Drug 
Administration (FDA)-approved tests. 
 
The Plan must follow Medicare rules. Medicare rules say that next-generation sequencing panels that evaluate 
multiple genes should be reported with a single panel code.  
 
 
 
 In this case, this single panel was reported with multiple individual gene codes. This is not in accordance with 
Medicare billing rules. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel 
provided on July 15, 2021.