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

 
We decided that the Plan does not have to pay for barium swallow studies (74230, 74240) provided on October 
31, 2022. 
 
You asked the Plan to pay for a barium swallow studies. You say that the services were medically necessary. 
The Plan denied your request. The Plan says documentation supports the studies were performed at a nursing 
home which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that certain types of imaging are not covered by 
Medicare in the mobile setting.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a barium swallow studies have not been met. Therefore, we decided that the Plan does not have to 
pay for barium swallow studies (74230, 74240) provided on October 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the wound PCR (polymerase chain reaction) panel (87798, 87801) 
provided on June 10, 2022. 
 
You asked the Plan to pay for the wound PCR panel. You say that these services were medically necessary and 
are supported in the medical record. The Plan denied your request. The Plan says that this panel was not billed 
in accordance with Medicare guidelines. 
 
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. Specifically, the Plan does not cite the rule used to deny payment of these 
services. We were unable to locate this information in a determination which applies to the state where these 
services were provided. The Plan has provided no other reason for denial of these services. The Plan's denial is 
not substantiated in this case. Therefore, we decided that the Plan has to pay for the wound PCR (polymerase 
chain reaction) panel (87798, 87801) provided on June 10, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of swallowing function, with 
cineradiography/videoradiography with contrast (74230), and upper gastrointestinal tract x-ray with contrast 
(74240) provided on October 28, 2022. 
 
You asked the Plan to pay for the x-rays with contrast. You say that the provider is contracted with this facility. 
You say that the enrollee's care team documented a limitation to transporting the enrollee. You also say that 
these services should be paid. The Plan denied your request. The Plan says the services in this case are not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures and examinations which are not 
covered under the portable x-ray provision include procedures involving the use of contrast media. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the x-rays with contrast have not been met. Therefore, we decided that the Plan does not have to 
pay for the x-ray of swallowing function, with cineradiography/videoradiography with contrast (74230), and 
upper gastrointestinal tract x-ray with contrast (74240) provided on October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an Otto Bock Taleo Vertical Shock (L5987, L5984). 
 
You asked the Plan to pre-approve an Otto Bock Taleo Vertical Shock. You say that the enrollee is eager to 
receive the replacement prosthesis with the appropriate foot system so that they may continue to advance their 
rehabilitation. The Plan denied your request. The Plan says that the request for K3 foot exceeds the enrollee's 
need and cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that certain prosthesis components may be covered when 
the enrollee's functional level is appropriate and supported. 
 
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 Otto Bock Taleo Vertical Shock. 
Our reviewer says that the requested prosthesis is medically necessary. Our physician reviewer found that the 
documentation provided does support the use of the requested prosthetic K3 component. The reviewer found 
that the enrollee requires a new prosthesis given volume change in the residual limb. The reviewer found that 
the enrollee's current K2 prosthetic components on the preparatory prosthesis do not match the current 
functional level, which is K3. The enrollee is currently ambulating for long distances and on uneven terrain 
with their current prosthesis with and without an assistive device per the clinical progress note. Therefore, the 
requested Otto Bock Taleo Vertical Shock (L5987, L5984) 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 an Otto Bock Taleo Vertical Shock have been met. Therefore, we decided that 
the Plan has to pre-approve an Otto Bock Taleo Vertical Shock (L5987, L5984).  
 
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: 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 enrollee's physical and occupational therapy 
needs are strongly recommended in an inpatient Rehabilitation Hospital to optimize mobility prior to returning 
home and meets full criteria for an inpatient acute rehabilitation stay. The Plan denied your request. The Plan 
says the enrollee's records do not show that you have complex rehabilitation needs that require frequent 
evaluation by a rehabilitation doctor, services needed can be provided safely in other settings, a skilled nursing 
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 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 inpatient rehabilitation facility, 
medically necessary care may be provided safely in 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a positron emission tomography (PET) 
scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found the criteria to 
cover a PET scan are not met in this case. 
 
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 positron emission tomography (PET) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 Prolia. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the review has determined that the 
documentation support that the Prolia is medically reasonable and necessary for the enrollee. The 
documentation supports that the Prolia is safe and effective 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a positron emission tomography (PET) 
scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
submitted records indicate that there are no behavioral disorders.  Thus, a differential diagnosis of Alzheimer's 
disease and frontotemporal dementia (FTD) is not mentioned.  Such a differential is required to meet criteria in 
order for a PET scan to be covered. 
 
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 positron emission tomography (PET) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99213 provided on August 4, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's 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 99213 is percutaneous vertebroplasty (bone biopsy 
included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; 
lumbosacral. 
 
We find that CPT code 99213 is not supported in the medical record. Specifically, this code was billed within 
the global value of surgery procedure 27130 (arthroplasty, acetabular and proximal femoral prosthetic 
replacement (total hip arthroplasty), with or without autograft or allograft). Without an appropriate modifier, 
this means payment for code 99213 is included within the global surgery period of code 27130 and is not 
separately payable as billed.  
Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99213 provided on August 4, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine. 
 
You asked the Plan to pre-approve Promethazine. You say that Promethazine is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Promethazine.  
 
Benefits for Promethazine 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 Lucentis. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has central retinal vein 
occlusion of the left eye with macular edema. She has not tried and failed the Plan's required drug, at least three 
months of Avastin. The records do not show that the required drug would be contraindicated or less effective; 
therefore, Lucentis is 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 Lucentis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 08, 
2022, to May 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $1,950 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,950 copayment for inpatient hospital care. 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 inpatient 
hospital care provided on May 08, 2022, to May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abutment supported porcelain fused to metal crown 
(predominantly base metal) (D6060 x2) and prefabricated abutment-includes modification and placement 
(D6056 x2) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting the Plan pay for your crowns 
as they have done in prior years. The Plan denied your request. The Plan says these services are not included in 
your dental coverage and no payment can be made. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for abutment 
supported porcelain fused to metal crown (predominantly base metal) (D6060 x2) and prefabricated abutment-
includes modification and placement (D6056 x2) provided on August 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) assessment. 
 
You asked the Plan to pre-approve a BIS assessment. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 a BIS assessment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bioimpedance devices for detection of lymphedema are considered investigational. 
The review has determined that the items/services at issue in this case are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a BIS assessment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a bioimpedance spectroscopy (BIS) assessment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95870, 95939, 95938, 95822, 95937, and 
95927 billed for date of service December 3, 2021. 
 
You asked the Plan to pay for procedure codes 95870, 95939, 95938, 95822, 95937, and 95927. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says these codes are included in the 
facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 95870, 95939, 95938, 
95822, 95937, and 95927. This means there is both a professional and technical component for the CPT codes. 
In this case, an appropriate modifier to indicate the professional component has not been billed with CPT codes 
95870, 95939, 95938, 95822, 95937, and 95927. Based on this information, we decided that Medicare rules for 
coverage of procedure code 95870, 95939, 95938, 95822, 95937, and 95927 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 95870, 95939, 95938, 95822, 95937, and 95927 
billed for date of service December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing identified with code 81345 provided on October 
6, 2022. 
 
You asked the Plan to pay for the testing. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange.  
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing identified with code 81345 
provided on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 25, 2020. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says according to 
Medicare Manual Chapter 1 Sections 70.1 and 70.4 it states, in general, such claims must be filed to the 
appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date 
the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit was not filed until September 29, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on November 11, 2022. 
 
You asked the Plan to pay for acupuncture. The Plan denied your request. The Plan says Acupuncturists are not 
able to be reimbursed by Medicare. Acupuncturists are included in the list of individuals are not eligible to 
enroll in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that an Acupuncturist is not eligible to participate in 
the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is an Acupuncturist. Medicare says 
that an Acupuncturist is not eligible to participate in the Medicare program.  Therefore, we decided that the 
Plan does not have to pay for acupuncture provided on November 11, 2022.