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

 
We decided that the Plan does not have to pre-approve 36 visits for therapeutic repetitive transcranial magnetic 
stimulation (TMS) treatment; subsequent delivery and management, per session (90868). 
 
You asked the Plan to pre-approve . You say that the enrollee meets the criterion, and you are requesting a 
comprehensive appeal review. The Plan denied your request. The Plan says the enrollee does not meet the 
Medically necessary criteria 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Based on review the records provided and utilizing the Medicare local coverage determination LCD 
specifically for repetitive transcranial magnetic stimulation (L37088) specifically requires the confirmed 
diagnosis to be Severe Major Depressive Disorder Single or Recurrent as well as resistance the treatment with 
pharmacologic agents as evidenced by lack of clinical significant response to for trials of pharmacologic agents 
in the current depressive episode from at least three different agent classes along with concurrent documented 
psychotherapy. This patient has been diagnosed with Bipolar Disorder Type II. The patient had not been tried 
on 3 antidepressants from 3 different classes throughout the documentation. Utilizing the information from this 
enrollee that indicates this patient does not have an indication for the requested Repetitive Transcranial 
Magnetic Stimulation (rTMS). Based on the records provided this patient does not meet the criteria for the use 
of Repetitive Transcranial Magnetic Stimulation (rTMS) based on the LCD. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of  have not been met. Therefore, we decided that the Plan does not have to pre-
approve 36 visits for therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent 
delivery and management, per session (90868).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on October 6, 2021. 
 
You asked the Plan to pay for the lab testing. You say that this was medically necessary testing that should be 
paid. The Plan denied your request. The Plan says the claim was not billed with an appropriate POS that 
matches the location in which the sample was taken. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab testing have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory testing provided on October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services 
you and/or your provider are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care facility. There are no services available at the LTACH that you require that are not available at the 
health care setting being offered by the health Plan. The health Plan has approved ongoing care in the current 
acute care facility.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use is not supported. 
 
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 Ilumya. Our reviewer says that the 
requested use of Ilumya is not supported. Our physician reviewer found although Ilumya is Food and Drug 
Administration-approved for the enrollees diagnosis, the use in combination with Otezla is not supported by 
the Medicare-approved major drug compendia or current medical society guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B 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 Gemtesa.  
 
Benefits for Gemtesa 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: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost for the iodine (A9516) and waive the cost for the 
radiopharmaceutical therapy (79005). We decided that the Plan does not have to waive the copayment for the 
thyroid imaging (78014).  
 
You asked the Plan to waive the copayment for radiology services. You say that you thought these services 
were covered. The Plan says that the copayment applied correctly. 
 
We decided that the Plan has to reduce the cost for the iodine (A9516) and waive the cost for the 
radiopharmaceutical therapy (79005).  
 
The Plan says that you must pay $110.22 for the iodine (A9516). The iodine (A9516) is considered a medical 
supply not diagnostic imaging. The Plan contract clearly says that you only pay 20% coinsurance for medical 
supplies. The allowed amount for the iodine (A9516) is $260 (20% x $260 = $52). Therefore, we decided that 
the Plan has to reduce the cost for the iodine (A9516) from $110.22 to $52. 
 
The radiopharmaceutical therapy (79005) is considered a component of a nuclear medicine procedure. We 
looked at your contract with the Plan. We did not see where the contract says the diagnostic imaging 
copayment applies to nuclear medicine procedures. The Plan contract does not clearly say how much enrollees 
must pay for nuclear medicine procedures. This means that the Plan did not follow Medicare rules for 
disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the cost for the 
radiopharmaceutical therapy (79005). 
 
We also decided that the Plan does not have to waive the copayment for the thyroid imaging (78014). 
 
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 $250 
copayment for each Medicare-covered diagnostic imaging service. You have only been asked to pay $241, 
which is less than the standard $250 copayment for the thyroid imaging (78014). Therefore, we decided that the 
Plan does not have to waive the copayment for thyroid imaging (78014). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140) provided by a participating provider on 
January 14, 2022. 
 
You asked the Plan to pay for extractions. You say that you should not have to pay for anything. The Plan 
denied your request. The Plan says this service has been correctly denied. 
 
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 
extractions (D7140) provided by a participating provider on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart monitor, insertion, subcutaneous cardiac rhythm 
monitor, including programming (33285). 
 
You asked the Plan to pre-approve a heart monitor. You say that the requested monitor is medically necessary. 
The Plan denied your request. The Plan says the requested monitor does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a heart monitor. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR.  In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in this enrollees clinical management. 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 heart monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heart monitor, insertion, subcutaneous cardiac rhythm monitor, including programming 
(33285).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (36415, 83605, 80053, 87040, 
73630, 99284) provided August 13, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 36415, 83605, 80053, 87040, 73630, & 99284 is not supported in the medical record. 
Specifically, the claim was billed with an invalid primary diagnosis code. Based on this information, we 
decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we 
decided that the Plan does not have to pay for emergency room services (36415, 83605, 80053, 87040, 73630, 
99284) provided August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and the psychotherapy service 
(90833) rendered by the out-of-network (OON) provider on October 28, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
 
 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99214) and the psychotherapy service (90833) rendered by the 
out-of-network (OON) provider on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and the scanning computerized 
ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral (92133) 
rendered by the out-of-network (OON) provider on March 3, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99214) and the scanning computerized ophthalmic diagnostic 
imaging, posterior segment, with interpretation and report, unilateral or bilateral (92133) rendered by the out-
of-network (OON) provider on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services provided on November 15, 2021. 
 
You asked the Plan to pay for office services. The Plan denied your request. The Plan says Medicare rules 
allow the Plan to restrict members to our network and deny out of network care except in rare circumstances. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for office services provided on November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance angiography (70548) provided on 
December 31, 2021. 
 
You asked the Plan to pay for a magnetic resonance angiography. You say that the enrollee had multiple 
exams. The Plan denied your request. The Plan says this cannot be paid 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, we have confirmed that code 70548 
is a column II code to column I code 70540. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a magnetic resonance angiography (70548) provided on 
December 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on January 26, 2022. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met 
because the CPT code at issue is inclusive to another billed code. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (70450) 
provided on January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says ongoing medical needs can be provided at a lower level of care. 
 
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 you are medically stable and do not meet the criteria for this admission. You do not 
need physician supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions.  No acute rehab nursing needs identified or documented in the record. At the current functional mobility level, 
you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. IRF admission is not medically necessary based on lack of medical 
complexity, and acute rehab nursing needs and current functional status at minimum assistance. Rehab needs 
can be met safely and provided in a lower intensity setting. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the transthoracic echocardiography (93306) provided on December 7, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for this service by a contract provider. The file does not show that the plan provided 
notice that this service would not be covered. Under Medicare rules, this means this service is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the transthoracic echocardiography 
(93306) provided on December 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lightweight wheelchair (K0003) provided July 4, 2021 to 
August 3, 2021. 
 
You asked the Plan to pay for the lightweight wheelchair. You say that this item was medically necessary. The 
Plan denied your request. The Plan says the code billed is not supported by the records provided. 
 
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 find that CPT code K0003 is not supported in the medical record. Specifically, there is a more appropriate 
code for the type of wheelchair provided (K0002). This code was already approved. Based on this information, 
we decided that Medicare rules for coverage of the lightweight wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pay for a lightweight wheelchair (K0003) provided July 4, 2021 to 
August 3, 2021.