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

 
We decided that the Plan does not have to pay for the office visit (99205, G0439), provided on January 7, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service should be covered. The Plan denied your 
request. The Plan says the services were obtained out-of-network. 
 
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 the office visit (99205, G0439), provided on 
January 7, 2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on November 23, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that the provider rendered medically 
necessary care in good faith and should be reimbursed. The Plan denied your request. The Plan says there was 
no documentation of a consultation with a primary care or attending physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on November 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab (CPT code J0897). 
 
You asked the Plan to pre-approve the medication. You say that you want to use use this medicine to treat the 
side effects of the medications for the enrollee's Prostate Cancer. The Plan denied your request. The Plan says 
there is no indication the enrollee has bone metastases or that the enrollee is receiving androgen deprivation 
therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of prostate cancer. The record indicates that the 
enrollee does not have a diagnosis of osteoporosis and is not receiving androgen deprivation therapy. The Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot 
be 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Denosumab (CPT code J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. 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. Medicare rules say that RFA is covered when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has cervical spondylosis 
without myelopathy or radiculopathy. He has had conservative treatment, including physical therapy. He had a 
diagnostic medial branch block (MBB) on March 29, 2022. He has only had one MBB and does not meet the 
criteria for RFA. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the chest, office 
visits, and associated procedures provided from January 12, 2022, to January 13, 2022, by the out of network 
provider. 
 
You asked the Plan to pay for the physician services. You say that your local oncologist diagnosed you with a 
rare and aggressive type of cancer. You say that it was suggested to you to seek a second opinion at a larger 
cancer center. You say that you tried to coordinate authorization between the out of network provider and your 
plan. You also say that the pre-surgery testing revealed that you did not have the rare and aggressive cancer 
you were initially diagnosed with. The Plan denied your request. The Plan says services received out of 
network are not covered. 
 
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 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 the computed tomography (CT) scan of the chest, 
office visits, and associated procedures provided from January 12, 2022, to January 13, 2022, by the out of 
network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nivolumab (Opdivo), ipilimumab (Yervoy), and 
zoledronic acid. 
 
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 the use of this drug/regimen is not reasonable and necessary. The Plan 
states their physician reviewer determined that the member has: a recently returned actionable marker- ALK 
(+). The Plan states the documentation does NOT support that the member has: no actionable markers. The 
Plan states the requested regimen was planned, pending the marker results and the provider has changed the 
plan to one using Alecensa. 
 
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 nivolumab (Opdivo), ipilimumab (Yervoy), and zoledronic acid, 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 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 nivolumab (Opdivo), ipilimumab (Yervoy), and zoledronic acid.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone hydrochloride (HCL) extended release. 
 
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 the requested drug is intended for patient 'self-administration'. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone hydrochloride 
(HCL) extended release.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient readmission, provided on November 5, 2021, 
through November 11, 2021. 
 
You asked the Plan to pay for the inpatient readmission. You say that the service should be covered. The Plan 
denied your request. The Plan says this patient had recently left the hospital and was sent home November 1, 
2021, earlier for the same/related diagnosis with instructions to return for planned surgery  
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient readmission. Our reviewer says 
that  Our physician reviewer found  
 
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 inpatient readmission have not been met. Specifically, the patient was 
readmitted to a hospital for care that, pursuant to professionally recognized standards of health care, could have 
been provided during the first admission. Therefore, we decided that the Plan does not have to pay for the 
inpatient readmission, provided on November 5, 2021, through November 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you strongly believe that the Intracept 
procedure is medically necessary and the most effective treatment for the enrollee at this time. The Plan denied 
your request. The Plan says medical studies have not proven that this procedure is helpful for the treatment of 
the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  The rules also say that experimental and investigational devices are not covered. 
 
We looked at 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, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower bench. 
 
You asked the Plan to pre-approve a shower bench. The Plan denied your request. The Plan says it does not 
mainly service a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
We looked at the file and the rules. While a shower chair may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a 
shower bench.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services (84156) provided on October 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is not a 
covered service. 
 
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. The Plan argues that this is not a covered service. However, the Plan has not 
provided documentation showing that this code is not covered. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (84156) provided 
on October 27, 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: Favorable

 
We decided that the Plan has to pay for the gene panel provided on December 3, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel detects somatic alterations. The Plan 
denied your request. The Plan says that one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and the rules. The claim provided shows the gene panel was billed with CPT code 81479. 
The Plan did not include any other claims or explanation of benefits to show that the services at issue were 
billed with multiple codes. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request. Based on this information, we decided that Medicare 
rules for coverage have been met. Therefore, we decided that the Plan has to pay for the gene panel provided 
on December 3, 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 PuraPly AM for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is investigational for a diabetic foot ulcer. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found it is well established that this patients diabetic ulceration to the right foot is responding slowly and 
poorly to routine debridement. The patients physician would like to expediate wound healing as they are 
concerned that an infection to the wound would complicate treatment and pose a greater risk for the patient. 
They have requested PuraPly AM applications. This is a Food and Drug Administration (FDA) approved 
wound covering design to provide an extracellular matrix for the wound and also reduce and/or eradicate 
biofilm. The requested PuraPly AM wound dressing is medically reasonable and necessary to treat this 
patients diabetic ulceration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve PuraPly AM for the enrollee.  
 
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 blood smear interpretation provided on February 5, 2022, 
billed with code 85060. 
 
You asked the Plan to pay for the blood smear interpretation as billed. You say that this is correctly billed and 
should be paid. The Plan denied your request. The Plan says this is not payable in the reported Place of Service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 85060 has a Pro/Tech Flag of 8 in the Physician Fee Schedule. This indicator identifies the 
professional component of clinical laboratory codes for which separate payment may be made only if the 
physician interprets an abnormal smear for hospital inpatient. This applies to CPT codes 88141, 85060 and 
HCPCS code P3001-26. No TC billing is recognized because payment for the underlying clinical laboratory 
test is made to the hospital, generally through the PPS rate. No payment is recognized for CPT codes 88141, 
85060 or HCPCS code P3001-26 furnished to hospital outpatients or non-hospital patients.  
 The documentation supports that the enrollee was a hospital outpatient. Based on this information, we decided 
that Medicare rules for coverage of the blood smear interpretation as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the blood smear interpretation provided on February 5, 2022, 
billed with code 85060.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the acupuncture services. You say that the services should be covered as 
you cannot wait until July to have them done by an in-network provider. The Plan denied your request. The 
Plan says the services denied correctly as the Plan will not refer you to a non-network provider. 
 
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 
acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on 
March 17, 2021. 
 
You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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 88305 is Level IV - Surgical pathology, gross and 
microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis 
Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical 
margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy 
Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, 
fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection 
Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge 
resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy 
Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or 
without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary 
tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, 
colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, 
paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other 
than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than 
tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy 
Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse 
Vagina, biopsy Vulva/labia, biopsy. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, this code has a professional 
component/technical component indicator of 1. This means this code must be submitted with modifier 26. 
Review of the file does not support that this code was submitted with the required modifier. Based on this 
information, we decided that Medicare rules for coverage of the surgical pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88305 
provided on March 17, 2021.