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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for procedure code 76641. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 2, 2022.
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 20, 
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 20, 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 an LTACH is better suited to meet the 
enrollee's needs. The Plan denied your request. The Plan says there appears to be no further need for LTACH 
level of vent weaning and further therapy can be performed at a lower level of care setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee 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: 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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 the enrollee was admitted to the hospital for surgical repair of a hip fracture after a 
fall and respiratory failure. He is now medically stable with no complex nursing or rehabilitation needs. He 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services (11721, 99213) provided on January 6, 
2022 to February 23, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that this service should be covered. The provider 
is in-network and the services were medically necessary. 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 $1,000 
deductible for all covered services 
 
You have been asked to pay $426.03 for the podiatry services. At the time services were rendered, the $1,000 
deductible was not met. 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 pay for podiatry services (11721, 99213) provided on 
January 6, 2022 to February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on January 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and were reported 
correctly. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services (81479) provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) (77014, 77370, 
77387, 77520, 77523, 77525). 
 
 You asked the Plan to pre-approve PBRT. You say that the requested therapy is medically necessary. The Plan 
denied your request. The Plan says the requested service does not meet the Medicare or health plan coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has early-stage lung cancer, perhaps centrally located, though it is described as 
being located in the right apex while a previously treated lung cancer was in the left lung. Proton therapy is an 
accepted, safe and effective treatment modality for lung cancer. It is not clear however, that proton therapy 
affords any benefit over SBRT or IMRT for a discrete nodule from clinically diagnosed lung cancer.  Though 
the apparent dose distribution would likely be somewhat better with proton therapy versus conventional 3D 
conformal radiation, the clinical benefit of this is not known. Furthermore, because lung tumors are moving 
targets, motion management would be needed. It is not clear how this is being offered in this situation (the 
orders describe the use of respiratory management). Technologies such as 4D-CT, image-guided radiation 
(IGRT) and stereotactic body radiation (SBRT) allow lung sparing by reducing the lung exposure. These 
technologies, which are the standard of care for treating discrete lesions from lung cancer, allow excellent 
coverage of the tumor with minimal dose to the surrounding tissue. There is no evidence that proton therapy is 
needed over other accepted treatments. There is no plausible reason that proton therapy would be more 
beneficial than standard therapy for this particular 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 PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT) (77014, 77370, 77387, 77520, 77523, 77525).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (64628 and 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutrition supplements. 
 
You asked the Plan to pre-approve nutritional supplements. You say that this is needed because the enrollee's 
oral intake is unable to meet 100% of nutritional needs while balancing protein loss due to dialysis. The Plan 
denied your request. The Plan says this is not covered because the enrollee is able to eat by mouth and has no 
documented impairment of the digestive tract. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve enteral nutrition supplements.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain 
(70553). 
 
You asked the Plan to pre-approve an MRI of the brain. You say that you need this and were told you needed 
authorization to be scheduled. The Plan denied your request. The Plan says medical records or a physician 
order have not been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an MRI of the brain have been met. 
Medical records, a physician order, or other documentation to support that an MRI is medically necessary have 
not been submitted. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance 
imaging (MRI) of the brain (70553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
You asked the Plan to pre-approve IRF care. You say that you need to have rehab to build strength to do your 
daily living actives like showering, dressing, walking. Your left side is weaker than the right side from the 
stroke. The Plan denied your request. The Plan says according to the available records, you do not meet all the 
required Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
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 your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA) of the head 
(70544). 
 
You asked the Plan to pre-approve an MRA of the head. The Plan denied your request. The Plan says the 
requested service is not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that all of the criteria listed in the Medicare rules section 
of this letter must apply in order for Medicare to provide coverage for an MRA of the head and neck. 
 
 
 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 MRA of the head. Our reviewer says 
that the medical necessity of the requested MRA of the head has not been established in the records submitted. 
Our physician reviewer found no abnormal findings on carotid ultrasound, a negative neurological exam, and 
no headaches or family history of aneurysm. Our reviewer also found that cardiology and pulmonary consults 
are pending, so without those results, approval for an MRA of the brain is not yet indicated. 
 
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 MRA of the head have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance angiography (MRA) of the head (70544).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator. 
 
You asked the Plan to pre-approve peripheral nerve stimulator. You say that the enrollee has been cleared to go 
through the peripheral nerve stimulator procedure. The Plan denied your request. The Plan says this procedure 
is not covered by Medicare. 
 
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 peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental for knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral nerve stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that you are in pain, and it is shooting down your right 
leg. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI of the lumbar spine is not medically necessary. Our physician reviewer found that the record indicates that 
the enrollee has lumbar radiculopathy. The record provided is insufficient to establish the medical necessity of 
the requested service at this time. The requested service is not medically necessary and reasonable for the 
diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria 
are not satisfied. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve white glass with metal crown (D2751) Tooth 13. 
 
You asked the Plan to pre-approve dental service. You say that the tooth is chipped and would need it replaced 
before something happens later on. The Plan denied your request. The Plan says that the x-ray's do not show 
that you have a cavity under the old cap. It is not medically necessary to replace the cap on the tooth. 
 
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 dental service 
when the services are medically necessary and reasonable. 
 
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 dental service. Our physician reviewer 
found a review of the documentation indicates the presence of a defective crown on tooth #13. The porcelain is 
fractured and there appears to be a mesial open contact as a result. It is medically reasonable and necessary to 
replace the crown to correct the defect and to prevent a more serious issue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental service have been met. Therefore, we decided that the Plan has to pre-
approve white glass with metal crown (D2751) Tooth 13.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 sensor. You say that you disagree with the denial for the 
Freestyle Libre 3 sensor. The Plan denied your request. The Plan says that you are requesting a CGM product 
that does not meet Medicare's definition of durable medical equipment (DME) and, therefore, is not in a 
defined Medicare benefit category. 
 
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 records show that you are requesting coverage of a non-
adjunctive CGM. As of January 1, 2023, the appropriate coding for a non-adjunctive CGM is E2103. The 
Freestyle Libre 3 is not specified as a product that may be billed using code E2103. Therefore, the Freestyle 
Libre 3 is not eligible for reimbursement. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 3 sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the services at issue have been billed 
correctly. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 22, 2022.