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

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that your provider verified this is your last 
option besides major back surgery. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because you have not had a psychological evaluation showing that you are a candidate 
for a spinal cord stimulator or that you have a covered indication for one. 
 
The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered if certain 
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 spinal cord stimulator. Our reviewer 
says that you do not meet the Medicare criteria for a spinal cord stimulator. Our physician reviewer found you 
do not have an evidence-based indication for a spinal cord stimulator trial. Also, no psychological evaluation 
was submitted for review to show that you are a candidate for a spinal cord stimulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft on tooth #12 (D4263) and 
guided tissue regeneration on tooth #12 (D4267). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the requested services are not covered by the dental benefits. 
 
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 pre-approve a 
bone replacement graft on tooth #12 (D4263) and guided tissue regeneration on tooth #12 (D4267).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on April 4, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you only had a COVID-19 test you 
didn't have any kind of medical examination so the charge should be waived. The Plan denied your request. 
The Plan says the copayment applied is correct. 
 
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 $10 
copayment for each Medicare covered visit with a PCP.  
 
You have been asked to pay $10 copayment for office visit. Office visits fall within the Physician/Practitioner 
Services, Including Doctors Office Visits 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 office visit provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office consultation. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-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 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 office consultation to be provided by an out-of-network (OON) provider.
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 IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical-necessity rules for IRF care have not been met. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 the 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says medical-necessity rules for coverage of the requested treatment 
have not been met because you have already had two courses of treatment with Orthovisc. 
 
The Plan follows Medicare rules. Medicare rules say that repeat injections for shoulder arthritis are limited to a 
single repeat course. 
 
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 treatment is not medically reasonable and necessary in this case. Our physician reviewer found that 
there is limited published, large-scale, long-term peer-reviewed literature that shows the requested treatment to 
be an effective and/or safe treatment for your pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 treatment with Orthovisc (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and chiropractic manipulative treatment. 
 
You asked the Plan to pre-approve an office visit and chiropractic manipulative treatment. You say that you 
feel chiropractic services should be covered due to you falling at the doctors office. The Plan denied your 
request. The Plan says you must have a diagnosis of subluxation demonstrated by an x-ray or physical exam. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Additionally, records show 
that you were diagnosed with cervicalgia, which is pain in the neck.  Therefore, we decided that the Plan does 
not have to pre-approve an office visit and chiropractic manipulative treatment.
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 LTACH services. You say that the requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for LTACH 
care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine capacity measurement (51798) provided on 
September 21, 2021. 
 
You asked the Plan to pay for the urine capacity measurement (51798). You say that the documentation 
supports CPT code 51798, and the claim should be reprocessed for payment. The Plan denied your request. The 
Plan says the medical records do not indicate this service was performed. 
 
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 51798 is measurement of post-voiding residual urine 
and/or bladder capacity by ultrasound, non-imaging. 
 
  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 urine capacity measurement (51798). Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found the procedure report does not include documentation of post-void residual measurement. Therefore, this 
procedure cannot be verified. 
 
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 urine capacity measurement (51798) have not been met. Therefore, we 
decided that the Plan does not have to pay for the urine capacity measurement (51798) provided on September 
21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of Keytruda in the setting of TMB-H negative, 
MSI-H indeterminate tumors Has not been demonstrated in the peer-reviewed literature. 
 
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 Keytruda 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 Keytruda (CPT code J9271).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lorazepam tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Lorazepam is a self-administered drug and medication does not fall under Part B 
coverage. 
 
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 Lorazepam tablet.   
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 pre-approve ImpediMed L-dex testing services. 
 
You asked the Plan to pre-approve ImpediMed L-dex testing services. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the use of bioimpedance spectroscopy 
for lymphedema is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy. 
 
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 ImpediMed L-dex testing services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is insufficient medical documentation that this enrollee will be at 
high risk of lymphedema. There is no documented surgical plan detailed to support a high risk of lymphedema. 
Separately, there is limited data to support the efficacy and improved outcomes of the ImpediMed L-dex testing 
for this enrollee given the limited published data with only 10% reported improvement above standard 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ImpediMed L-dex testing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ImpediMed L-dex testing services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Letrozole 2.5MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Letrozole is a self-administered drug and does not fall under Part B coverage. 
 
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 Letrozole 2.5MG tablet.  
 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that medical-necessity rules have not been met because 
the requested drug has been prescribed for an off-label and not medically supported use. 
 
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 Opdivo. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Opdivo is FDA-approved for the enrollees diagnosis. The available medical documentation 
supports that the requested drug is safe and effective and otherwise reasonable and necessary for the 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 Opdivo have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Opdivo.  
 
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 gene panel testing provided on January 4, 2022. 
 You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the claim billed 
is inconsistent with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, there are insufficient medical records to show that the billing guidelines criteria have been met. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the gene panel testing provided on January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthesis and accessories to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee wishes to use this 
provider because they have an established relationship. The Plan denied your request. The Plan says there is an 
in-network provider that can perform the services the enrollee needs. 
 
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 
the prosthesis and accessories to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service November 
20, 2021. 
 
You asked the Plan to pay for code 99222. You say that medical records have been provided to support 
payment of this code. The Plan denied your request. The Plan says the documentation does not support the 
service billed because the medical records appear to be incomplete. The following was missing: any applicable 
physician information that may pertain to initial inpatient admission. 
 
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 99222 is Initial hospital care visit of moderate 
complexity. 
 
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 code 99222. Our reviewer says that code 99222 is not 
supported in the medical record. Our reviewer found the level of service supports a comprehensive history and 
exam, medical decision making of moderate complexity. In this case, code 99222 is not supported by documentation. Also, for payment of this service, the medical record is missing the emergency room visit to 
confirm an initial hospital care visit billed.  Physicians must use the initial hospital care codes (codes 99221-
99223) to report the first hospital inpatient encounter with the patient when he or she is the admitting physician. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99222 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99222 billed for date of service November 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation 
device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has chronic pain in the neck and 
lower back. The Plan denied your request. The Plan says that the requested auricular peripheral nerve 
stimulation (electro-acupuncture device) is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-
acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve placement of an auricular peripheral nerve stimulation device for the enrollee.