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

 
We decided that the Plan does not have to pay for acupuncture treatment provided from November 24, 2021, 
through December 6, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says this provider 
is not supervised by any physician, PA, or NP/CNS. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided from 
November 24, 2021, through December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110), reline complete 
mandibular denture (D5731), and a complete mandibular denture (D5120), provided by a participating provider 
on January 5, 2022. 
 
You asked the Plan to pay for a complete maxillary denture, reline complete mandibular denture, and a 
complete mandibular denture. You say that you got an injection with your old plates. The Plan denied your 
request. The Plan says the rendered dental services are not covered. 
 
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 a complete maxillary denture (D5110), reline complete mandibular denture (D5731), and a complete mandibular 
denture (D5120), provided by a participating provider on January 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on January 28, 
2022. 
 You asked the Plan to pay for an abdominal ultrasound. You say that you have provided records to support the 
service at issue. The Plan denied your request. The Plan says rules for payment have not been met because the 
CPT code at issue is inclusive to another billed code. 
 
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 an abdominal ultrasound (76705) provided on January 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Paclitaxel and Cisplatin for the enrollee. 
 
You asked the Plan to pre-approve Keytruda, Paclitaxel and Cisplatin. You say that these drugs are medically 
necessary. The Plan denied your request. The Plan says that the documentation does not support that the 
member has PDL1 positive disease. 
 
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 Keytruda, Paclitaxel and Cisplatin. Our 
reviewer says that Keytruda, Paclitaxel and Cisplatin are not medically reasonable and necessary. Keytruda, 
Paclitaxel and Cisplatin are not FDA-approved for the enrollee's diagnosis as the documentation in the case file 
does not support that the enrollee's cervical cancer expresses PD-L1. The use of these drugs is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda, 
Paclitaxel and Cisplatin.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Paclitaxel and Cisplatin have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Keytruda, Paclitaxel and Cisplatin for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to 
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of 
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary as the enrollee is 
improving and she will risk becoming weaker if her rehab stops now. The Plan denied your request. The Plan 
says IRF care is not medically necessary and the enrollee's needs can be met at a lower level of care such as in 
a skilled nursing facility or at home with home health services. 
 
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 while the enrollee may benefit from physical therapy, and occupational therapy, 
her rehab needs can be safely addressed at a low intensity alternate setting such as in an skilled nursing facility 
or in-home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pre-liver transplant evaluation. 
 
You asked the Plan to pre-approve a pre-liver transplant evaluation. You say that  The Plan denied your 
request. The Plan says a pre-liver transplant evaluation does not meet the Medicare criteria. 
 
The Plan follows Medicare rules.  
 
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 a pre-liver transplant evaluation. Our 
reviewer says that a pre-liver transplant evaluation is not medically necessary. Our physician reviewer found 
that interventional radiology (IR) treated you on March 9, 2022. IR planned to follow-up with you in 3-4 
months to evaluate if resection of the hepatocellular carcinoma (HCC) was possible. This may be determined at 
the planned 34-month follow-up with IR. Your body mass index (BMI) is 50. Per the transplant center a BMI 
greater than 35 is a relative contraindication to transplant. You have chronic portal vein occlusion. This is a 
relative contraindication to transplant per the transplant center and the Medicare NCD. This (macrovascular 
involvement) is a contraindication to transplant per the Medicare NCD. The review has determined that the 
requested pre-liver transplant evaluation does not meet the Medicare NCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pre-liver transplant evaluation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pre-liver transplant evaluation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on September 17, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says payment for 
this service would have been included under the facility claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. The claim shows the services were provided in an ambulatory surgical 
center. This service was provided via arrangement of the facility. Payment for this service would have been 
included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on 
this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and related 
supplies provided on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 24, 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 the services were not billed correctly. 
 
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 these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pre-approve the psychiatric diagnosis interview examination (90792). 
 
You asked the Plan to pre-approve the psychiatric diagnosis interview examination. You say that you have 
been under the care of this doctor for a few months but your psychiatric history and depressive symptoms 
stretch back many years. You have had many medication trials and failures over those years which is supported 
by your medical records. The Plan denied your request. The Plan says that the enrollee does not meet the 
medically necessary criteria. 
 
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 pre-approve the psychiatric diagnosis interview 
examination. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found based on the information provided this enrollee does meet 
the clinical criteria for the use of TMS therapy utilizing LCD L37088 as she carries a diagnosis of Dysthymia 
and Bipolar Disorder Type II. Utilizing the information from this enrollee that indicates she does have an 
indication for the requested Repetitive Transcranial Magnetic Stimulation (rTMS). This enrollee does meet the 
criteria and the request for Repetitive Transcranial Magnetic Stimulation (rTMS) therapy is considered 
medically necessary for this enrollee who suffers from Dysthymia and Bipolar Disorder Type II. 
 
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 psychiatric diagnosis interview examination have been met. Therefore, we 
decided that the Plan has to pre-approve the psychiatric diagnosis interview examination (90792).  
 
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 a comprehensive oral evaluation (D0150) provided by a 
participating provider on September 40, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the benefit limit for D0150 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. The Plan covers one 
comprehensive oral evaluation every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on September 27, 2019. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) provided by a participating provider on September 40, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on November 23, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on November 23, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on November 1, 
2021. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says this service is supported not as 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. Based on this information, we decided that Medicare rules for coverage of 
critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first 
hour (99291) provided on November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orthovisc injection (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the enrollee has moderate to severe pain in their left 
knee. You say that the enrollee has received a corticosteroid injection. You also say that it was recommended the enrollee receive viscosupplementation injections if the corticosteroid injection did not provide relief. The 
Plan denied your request. The Plan says the criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all 
of the conditions are 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 Orthovisc. Our reviewer says that the 
requested Orthovisc injection is not medically necessary. Our physician reviewer found the provided 
documentation does not clearly define that the enrollee has failed three months of conservative therapy. 
Therefore, the reviewer found that the requested injection 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an Orthovisc injection (J7324).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the astigmatism-correcting procedure provided on April 19, 
2021. 
 
You asked the Plan to pay for the services provided. You say that you were told the surgery was approved. The 
Plan denied your request. The Plan says the service is not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism-
correcting procedure provided on April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on April 
26, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records submitted do not indicate that two separate services were performed/supported. 
 
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 74174 is "Computed tomographic angiography, abdomen 
and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing." 
 
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 the records show that a single 
computed tomography angiography (CTA) of the abdomen and pelvis was done on 4/26/21. There is no 
additional study for that same date. 
 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 additional imaging services provided to the enrollee on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services (CPT code 99204) to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that it is a necessary treatment. The 
Plan denied your request. The Plan says your records received do not indicate that you have an emergent or 
urgent medical condition or are in need of specialized service(s) that are not available in the network. The Plan 
states there are in-network provider(s) within a reasonable distance from your location that can provide this 
service or item and you can find a list of in-network providers in your Provider Directory. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found the record indicates that you have stage IV small cell lung cancer with brain metastases. The record provided is 
insufficient to show why the requested services must be provided on an out-of-network basis. The elements of 
the coverage criteria are not satisfied. The requested service is not 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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the office services (CPT code 99204) to be provided by an out-of-
network provider.