Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS) 
treatment. 
 
You asked the Plan to pre-approve repetitive transcranial magnetic stimulation (rTMS) treatment. You say that 
repetitive transcranial magnetic stimulation (rTMS) treatment is medically necessary. The Plan denied your 
request. The Plan says the requested rTMS does not meet the Medicare coverage 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 repetitive transcranial magnetic 
stimulation (rTMS) treatment. Our reviewer says that repetitive transcranial magnetic stimulation (rTMS) 
treatment is not medically necessary. Our physician reviewer found that based on review the records provided 
and utilizing the Medicare LCD, Transcranial Magnetic Stimulation (L34998) specifically states the 
confirmation of the diagnosis of severe major depressive disorder single or recurrent and one or more of the 
following, the patient has demonstrated resistance to treatment with psychopharmacologic agents as evidenced 
by lack of clinically significant response to for trials of such agents, in the current depressive episode from at 
least 2 different agent classes or the inability to tolerate pharmacologic agents is evidenced by 4 trials of 
psychopharmacologic agents with distinct side effects or history of response to Transcranial Magnetic 
Stimulation (TMS)  in a previous depressive episode evidenced by greater than 50 percent improvement in the 
standard rating scale or is currently receiving or is a candidate for and has declined electroconvulsive therapy 
and TMS is considered a less invasive treatment option and a trial of evidence-based psychotherapy known to 
be effective in the treatment of Major Depressive Disorder of an adequate frequency and duration without 
significant improvement in depressive symptoms as documented by standardized rating scales. Based on the 
information provided, you do not meet the clinical criteria for the use of Transcranial Magnetic Stimulation 
(TMS) therapy utilizing LCD (L34998) as you do not meet the severity of illness to require this type of 
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 repetitive transcranial magnetic stimulation (rTMS) treatment have not been 
met. Therefore, we decided that the Plan does not have to pre-approve repetitive transcranial magnetic 
stimulation (rTMS) treatment.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided on September 10, 2020. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
payment should not have been retracted. The Plan denied your request. The Plan says that the patient's primary 
insurance should be charged first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, there is nothing in the 
case file the Plan submitted to us indicating who the primary insurer is or proof that the patient even has other 
insurance.  In addition, the record does not show that the Plan has sent the bill directly to the primary insurer 
for payment, directed you to send the bill to the primary insurer or paid for the services and submitted a bill for 
reimbursement to the primary insurer. Therefore, we decided that the Plan has to pay for medical services 
provided on September 10, 2020.  
 
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 foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have developed plantar fasciitis while 
wearing a boot from her fall. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 17, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 17, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a positron emission tomography (PET) 
scan and a computed tomography (CT) scan provided on May 31, 2022, and June 13, 2022. 
 
You asked the Plan to waive the copayment for a PET scan and a CT scan. You say that this should be covered 
because you are on a fixed income and cannot afford this copayment. 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 $350 
copayment for outpatient diagnostic tests and therapeutic services and supplies. You have a $130.16 for the CT 
scan, which is less than the full copay amount + $350 for a PET scan = $480.16 ($130.16 + $350 = $$480.16). 
 
You have been asked to pay a $480.16 copayment for a PET scan and a CT scan. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies 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 a positron emission tomography 
(PET) scan and a computed tomography (CT) scan provided on May 31, 2022, and June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided on July 3, 2022, 
to July 8, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were told by hospital staff 
this would be covered at 100%. 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 $300 
copayment for inpatient hospital care.  There is a $300 copayment per inpatient stay with a maximum out of 
pocket (MOOP) of $900 copayment per year. At the time of these inpatient services, you had not reached the 
maximum out of pocket for inpatient copayments. 
 
You have been asked to pay a $300 copayment for an inpatient stay. This item/service falls within the inpatient 
hospital care 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 an inpatient stay provided on July 3, 2022, to 
July 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a knee injection provided on June 1, 2022, June 8, 
2022, and June 20, 2022. 
 
You asked the Plan to waive the cost for a knee injection. You say that you don't feel you should owe these 
large cost share amounts for 3 knee injections. 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 $20 
copayment for physician/practitioner services, including doctor's office visits, and a 20% coinsurance for 
Medicare Part B drugs.  
 
You have been asked to pay a $20 copayment for physician/practitioner services, including doctor's office 
visits, and a 20% coinsurance for Medicare Part B drugs for a knee injection. This item/service falls within the 
benefit Medicare Part B drugs, and physician/practitioner services, including doctor's office visits category.  
You have been asked to pay a total cost of $245.70 ($81.90 x 3 visits = $245.70) 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 cost for a knee injection provided on June 1, 2022, June 8, 2022, and June 
20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aubagio 14MG 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 Aubagio 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 Aubagio 14MG 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: Unfavorable

 
We decided that the Plan does not have to pre-approve Lutetium Lu 177 Dotatate (Lutathera). 
 
You asked the Plan to pre-approve Lutathera. You say that studies have demonstrated robust activity of this 
therapy. The Plan denied your request. The Plan says guidelines do not support the request for the enrollee's 
cancer. 
 The Plan must follow Medicare rules. Medicare rules say that 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. In this case, the medical records only include a medical study for the 
requested treatment. There are no medical records for the enrollee to show that the requested treatment is safe, 
effective, and/or medically reasonable to treat the enrollee. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve Lutetium Lu 177 Dotatate (Lutathera).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says they do not have record from the prescriber that shows the preferred drug 
has been tried, hasn't worked, or that there are medical reasons preventing its use. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
exudative macular degeneration.  The requested medication is a new start.  The provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred 
step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can receive further services at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on July 16, 2021.

You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable 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 81479 is unlisted molecular pathology procedure.

We find that CPT code 81479 is not supported in the medical record. Specifically, this service was billed with GZ modifier. This means this code is specifically not covered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81479 provided on July 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level of facet joint injections (64495). 
 
You asked the Plan to pre-approve a third level of facet joint injections. You say that this is medically 
necessary. The Plan denied your request. The Plan says a third level is not supported. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels of facet joint injections, either 
unilateral or bilateral, are allowed per session per spine region. 
 
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 third level of facet joint injections. 
Our reviewer says that the requirements for coverage of a third level of facet joint injections have not been met. 
Our physician reviewer found the records do not show that a third level is 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 a third level of facet joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a third level of facet joint injections (64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown restoration (D2740) provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve a crown restoration. You say that this service is medically necessary. The 
Plan denied your request. The Plan says D2740 is not medically necessary. 
 
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 a crown 
restoration 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 a crown restoration. Our reviewer says 
that a crown restoration is not medically necessary. Our physician reviewer found documentation provided did 
not show significant coronal breakdown to warrant a crown restoration (D2740) for tooth #7. 
 
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 a crown restoration have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown restoration (D2740) provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection between wheelchair controller 
and 2 or more power seating system motors. 
 You asked the Plan to pre-approve the electronic connection. You say that this equipment is medically 
necessary for the operation of your power wheelchair. The Plan denied your request. The Plan says the criteria 
for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the electronic connection is subject to the criteria 
listed 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 the electronic connection. Our reviewer 
says that the requested electronic connection is not medically reasonable and necessary. Our physician reviewer 
found that you have sufficient upper body mobility and strength to manage standard interface for multiple 
power drives and do not require a single interface. In this case, the requested equipment exceeds services or 
devices necessary to meet your needs 
 
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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection between wheelchair controller and 2 or more 
power seating system motors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your last denture was already broken and 
unusable. You say you are having trouble without teeth. The Plan denied your request. The Plan says your 
benefit for the requested item or service 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 25, 2018.  
 According to your dental benefit, you would not be eligible for coverage of a complete denture again until 
October 2023. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628).

You asked the Plan to pre-approve the intracept procedure. You say that the service is necessary. The Plan denied your request. The Plan says this service is considered experimental/investigational as it is not widely used and not generally accepted for the suggested use as reported in nationally recognized peer-reviewed medical literature.

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 to show safety and efficacy.

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 (CPT code 64628).