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

 
We decided that the Plan does not have to pre-approve continued Botox injections. 
 
You asked the Plan to pre-approve the Botox injections. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
{***Add rules/contract recap and to complete decision section. For example: 
 
"The Plan follows Medicare rules. Medicare rules say that Botulinum toxins will be covered when considered 
medically reasonable and necessary when administered for treatment of FDA-labeled indications and Off-label indications (as applicable). 
 
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 Botox injections. Our reviewer says 
that the continued injections are not medically necessary. Our physician reviewer found no documentation has 
been provided of benefit or adverse response to the Botox treatments provided thus far. 
 
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 Botox injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued Botox injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs rehabilitation in order to be 
restored to her pre-hospital condition. The Plan denied your request. The Plan says the SNF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a nursing home. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that the patient 
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Records 
do not document the need for intravenous medications, new tube feeding or ostomy care or daily complex 
wound care or respiratory care. Although the records document the patient is limited functionally, the provided 
records do not document a significant decline in the patients functional status compared to her recent baseline 
to necessitate daily inpatient skilled therapy services. Services in the long-term care facility on a part time basis 
are appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided October 3, 2022. 
 
You asked the Plan to pay for the office visit. You say that please see attached medical records showing 
medical necessity. Please reconsider the claim. The Plan denied your request. The Plan says 
missing/incomplete/invalid prior insurance carriers EOB (explanation of benefits). 
 
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 met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
carrier as the primary payer. As the secondary insurer, the Plan cannot be held responsible for the office visit 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for the outpatient office visit (99214) provided October 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84439 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 84439. You say that you are entitled to payment on one unit of 
the code billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   

In this case, the MUE for CPT code 84439 is [1]. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 84439 have not been met. You have the option of submitting a corrected claim with only one 
unit of service for consideration to the Plan. Therefore, we decided that the Plan does not have to pay for 
procedure code 84439 billed for date of service July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies and materials [except spectacles], provided by the 
physician or other qualified health care professional over and above those usually included with the office visit 
or other services rendered [list drugs, trays, supplies, or materials provided]) (99070) provided April 26, 2022 
 
You asked the Plan to pay for the surgical supplies. You say that you have submitted information needed to 
process you claim for reimbursement of necessary surgery you had recently. The doctor does not participate 
with insurance and procedures are paid for ahead of surgery. The Plan denied your request. The Plan says if 
you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of 
the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for supplies and materials [except 
spectacles], provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) 
(99070) provided April 26, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) provided on June 17, 2022, 
billed with code 95822. 
 
You asked the Plan to pay for the EEG as billed. You say that these services were medically necessary and 
should be reimbursed. The Plan denied your request. The Plan says two of the codes were approved for 
payment; however, code 95822 is not the most appropriate code for these services. 
 
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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. 
 
We find that CPT code 95822 is not supported in the medical record. Specifically, this testing was not done 
during coma or sleep, but rather during a procedure. There is a specific alternate code for this situation. Based 
on this information, we decided that Medicare rules for coverage of the EEG as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) provided on June 
17, 2022, billed with code 95822.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 62326 provided on August 10, 
2022. 
 
You asked the Plan to pay for the injection services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the code billed is not supported. 
 
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 62326 is injection(s), including indwelling catheter 
placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or 
subarachnoid, lumbar or sacral (caudal); without imaging guidance. 
 
We find that CPT code 62326 is not supported in the medical record. Specifically, the documentation indicates 
that injection, or diagnostic or therapeutic substance, not including neurolytic substances, including needle or 
catheter placement, interlaminar epidural or subarachnoid, lumbar; without imaging guidance was performed.  
 This means there is a more appropriate code to be billed for the services rendered. Based on this information, 
we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided 
that the Plan does not have to pay for the injection services coded 62326 provided on August 10, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear, peripheral, interpretation by physician with 
written report (85060) provided August 4, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that medical records documenting all billed 
units are shown on the attached pathology report, providing evidence of their medical necessity. Please review 
and reprocess for payment. The Plan denied your request. The Plan says the procedure code/type of bill is 
inconsistent with the place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that CPT code 85060 is not supported in the medical record. Specifically, this has an 
indicator or 8 which This indicator identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. This 
applies to CPT codes 88141, 85060 and HCPCS code P3001-26. No TC billing is recognized because payment 
for the underlying clinical laboratory test is made to the hospital, generally through the PPS rate. No payment is recognized for CPT codes 88141, 85060 or HCPCS code P3001-26 furnished to hospital outpatients or non- 
hospital patients. The physician interpretation is paid through the clinical laboratory fee schedule payment for 
the clinical laboratory test. You can find this in CMS Claims Processing Manual, Chapter 23, Section 50.6, 
Physician Fee Schedule Payment Policy Indicator File Record Layout. 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 blood smear, peripheral, interpretation by physician with written report 
(85060) provided August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. 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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the bottom line is that proton therapy for prostate cancer is not experimental, and in fact is an 
accepted treatment approach. While it is not thought that proton therapy is an experimental therapy, any 
potential benefit or detriment of proton therapy over standard Intensity modulated radiation therapy (IMRT) is 
an investigational question. Other treatment approaches (IMRT +/- Image-guided radiation therapy (IGRT)) are 
also highly effective and well tolerated. Thus, whether proton therapy affords a benefit over other standard 
approaches (IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial. Particularly 
with the use of the SpaceOAR hydrogel spacer, the risk of gastrointestinal (GI)/rectal toxicity is low (since the 
rectum is pushed away from the prostate) such it is even more unlikely that there would be a potential benefit 
from proton therapy. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton 
beam therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says that Keytruda as a 
single agent is not indicated by the National Comprehensive Cancer Network (NCCN) guidelines. 
 
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 Keytruda. Our reviewer says that 
Keytruda is medically reasonable and necessary for the enrollee. Our physician reviewer found the requested 
use of Keytruda is FDA-approved for the enrollees diagnosis. First-line, single-agent treatment of nonsmall 
cell lung cancer (NSCLC) in patients with metastatic NSCLC, and with tumors with programmed cell death 
ligand 1 (PD-L1) expression (tumor proportion score [TPS] greater than or equal to 1%), as determined by an 
approved test, and with no epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) 
genomic tumor aberrations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda (J9271).  
 
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 continuous glucose monitor (CGM) and supplies (KO553, K0554).

You asked the Plan to pay for the CGM and supplies. You say that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet the clinical requirements to be approved. The record indicates that you do not inject insulin 3 or more times per day.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies (KO553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223. 
 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 99497 
is a column II code to column I code 99223. 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 procedure code 99497 billed for date of service April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6219 and A6222 billed for date of service 
August 26, 2022. 
 
You asked the Plan to pay for procedure codes A6219 and A6222. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says procedure codes A6219 and 
A6222 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 procedure code. 
 
We find that procedure codes A6219 and A6222 have a status indicator of P on the Physician Fee Schedule. 
This means that procedure codes A6219 and A6222 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes A6219 and A6222 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A6219 and A6222 billed for date of service 
August 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for ambulance services provided on April 5, 2022.

You asked the Plan to waive the deductible and coinsurance for the ambulance services. You say that you were not given a choice of transportation. 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. Your contract with the Plan says that there is a $400 deductible which applies to certain items and services.

The item or service you asked the Plan to waive the deductible and coinsurance for falls within the ambulance services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible which applies to ambulance services. This cost sharing is a contractual obligation that had not been met at the time the ambulance services was received on April 5, 2022.

Once the $400 deductible was met, the 2% coinsurance was applied to the remaining amount of $777.37, for a total of $15.55. The total for the deductible and coinsurance is $415.55. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for ambulance services provided on April 5, 2022.
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 August 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement that indicates that these tests should be included in the dialysis rate. 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 August 
4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services billed with code 20611 for June 28, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 20611 is not supported. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording 
and reporting. 
 
We find that CPT code 20611 is not supported in the medical record. Specifically, the records indicate that a 
single trigger point injection was performed and there is a more appropriate code for these services. 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 pay for the injection services billed with code 20611 for June 28, 
2022.