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

 
We decided that the Plan does not have to pay for excision, malignant lesion including margins, scalp, neck, 
hands, feet, genitalia; excised diameter 1.1 to 2.0 cm provided to the enrollee on September 12, 2022. 
 
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 the records do not support the services 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, the CPT Code Manual definition of code 11622 is "Excision, malignant lesion including margins, 
scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that per CPT coding guidelines, CPT 
14040 includes the excision of a benign or malignant lesion - codes 11400 - 11446 and 11600 - 11646 are not 
separately payable. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised 
diameter 1.1 to 2.0 cm provided to the enrollee on September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SBRT (CPT code(s): 77370, 77373, 77470). 
 
You asked the Plan to pre-approve the SBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says there is evidence that this type of radiation is not needed and not effective for your 
cancer; therefore, it not considered standard of care. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found routine use of SBRT for induced oligometastases from breast cancer is not an accepted standard 
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 the SBRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve SBRT (CPT code(s): 77370, 77373, 77470).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service March 25, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. The Plan denied your request. The 
Plan says these codes are included in the facility payment and is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service March 25, 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 LTACH is the best option for the 
enrollee's care. The Plan denied your request. The Plan says LTACH admission is not medically necessary. 
 
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 appears to be improving and stable and should only require short-
term additional acute care services that can safely be provided at the current facility until more appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Completion of treatment at the current facility is recommended. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the provided medical records do not show that a two-midnight stay is needed and that care at an observation level would be inappropriate with the option to transition the enrollee to 
inpatient status if their condition warranted further hospital level 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that you received this wheelchair 
in January 2021, and it has been broken many times. The last repairs made you were told that there are no more 
parts for your chair, and you would need a new one. You are crippled and this is the only way you can get 
around. The Plan denied your request. The Plan says your current power wheelchair is under five years old and 
is not in disrepair.  
The Plan must follow Medicare rules. Medicare rules say that replacement may be reimbursed when a new 
physician order and/or new CMN, when required, is needed to reaffirm the medical necessity of the item. 
 
We looked at the file and Medicare rules. The records show that the vendor visited your home on November 
23, 2022, to make repairs and found that the current wheelchair was functional and did not require any repairs. 
Based on this information, we decided that Medicare rules for coverage of a replacement power wheelchair 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement power 
wheelchair.
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 you are requesting a reconsideration for the denied 
IRF services. The Plan denied your request. The Plan says a skilled nursing facility is an appropriate level of 
care because you have a wound vac and are unable to participate in 3 hours of daily therapy required for an IRF 
admission. 
 
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 or an intensive 
rehabilitation therapy program. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine mileage, per trip (A0170). 
 
You asked the Plan to pre-approve the additional mileage. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable 
transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.   
We looked at your request, the records in the case file, and the Plans rules. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Specifically, your 
request submitted to the Plan was for a total of 155 miles, per one-way trip. However, the Plan contract 
provides coverage for 50 miles of driving distance only for each trip. Therefore, your request exceeds the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to pre-approve additional 
routine mileage, per trip (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that the enrollee has type 2 diabetes 
and is currently treated with the requested products since 2019. You also say the enrollee tests two times per 
day and is not currently on insulin. The Plan denied your request. The Plan says the enrollee must perform 
glucose testing four times day, must be insulin treated with three or more daily injections, and must have an 
insulin regimen that requires frequent dosage adjustments. The enrollee does not meet coverage approval for 
the requested CGM sensor. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre CGM sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network coverage procedure to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a robotic laparoscopic retropubic radical prostatectomy. You say that you 
are scheduled for prostate surgery and although it is considered OON, it needs to be setup for in network. The 
provider was told that it was authorized and there should be no issue. The Plan denied your request. The Plan 
says if you use an out-of-network provider, your share of the costs for your covered services may be higher. 
The Plan has multiple in network qualified specialists that can provide this service. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an in-network coverage procedure to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service October 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.  
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service September 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code 64488. The Plan denied your request. The Plan says payment for 
code 64488 is bundled into payment for code 00840.  
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 64488 
is a column II code to column I code 00840. 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 64488 billed for date of service August 17, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for code 83880 billed for date of service March 30, 2022. 
 
You asked the Plan to pay for code 83880. You say that this code is payable with the diagnosis billed. The Plan 
denied your request. The Plan says that This service does not meet the coverage requirements in the applicable 
Local Coverage Determination (LCD) or National Coverage Determination (NCD). Related services performed 
in connection with the denied procedure are also not covered 
 
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's very limited case file only lists its denial reason as "This 
service does not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or 
National Coverage Determination (NCD)."  However, the Plan has provided no citation to a specific LCD or 
NCD upon which this decision was based.  The Plan has failed to provide any analysis as to which provisions 
of said LCD/NCD were not met.  The burden is on the Plan to submit sufficient evidence showing that its 
denial is supported, and the Plan has failed to do so in this case. Therefore, we decided that the Plan has to pay 
for code 83880 billed for date of service March 30, 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the methadone treatment rendered on July 13, 2022. 
 
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 the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that a registered nurse (RN) is not eligible to enroll in 
Medicare.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered by a registered nurse. 
This provider type is not eligible to enroll in and bill Medicare. Therefore, we decided that the Plan does not 
have to pay for the methadone treatment rendered on July 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Arthrocentesis (20610), provided on 
April 14, 2022, and April 21, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that the cost share is incorrect. 
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 $100 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $100 copayment for the outpatient surgery. This service falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 the Arthrocentesis 
(20610), provided on April 14, 2022, and April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl (luspatercept-aamt) (CPT code J0896). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says there is no clinical support available for using Reblozyl as treatment 
for the type of blood disorder that the enrollee has. The Plan also says without clinical support, treatment may 
not be medically necessary. 
 
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 medication. Our physician reviewer 
found the requested use of Reblozyl (luspatercept-aamt) (J0896) is not FDA-approved for the enrollees 
diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a 
Centers for Medicare & Medicaid Services (CMS)-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Reblozyl (luspatercept-aamt) (CPT code J0896).