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

 
We decided that the Plan does not have to pre-approve the cervical spinal magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve the cervical MRI. You say that the MRI is medically necessary. The Plan 
denied your request. The Plan says the MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the cervical MRI. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
neck pain radiating to left hand. The x-rays showed scoliosis and degenerative changes. However, there was no 
neurological examination and no attempt at conservative management of pain, including six weeks of physical 
therapy. 
 
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 cervical MRI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the cervical spinal magnetic resonance imaging (MRI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental in cases of spine surgery when used as bone graft material. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the treatment of a 
root canal obstruction; non-surgical access (D3331) provided on August 22, 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 these services are not covered benefits under 
your supplemental dental policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) and the treatment of a root canal obstruction; non-surgical access (D3331) provided on 
August 22, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dysport. 
 You asked the Plan to pre-approve Dysport. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been 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 Dysport. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
you have tried and failed the plan's preferred step one alternative. The record does not indicate that you have a 
contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dysport have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Dysport.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
21, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service December 21, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
16, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service December 16, 
2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 93010 billed for date of service September 9, 2021.

You asked the Plan to pay for procedure code 93010. You say that you have provided medical records to support payment. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 25600.

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 93010 is a column II code to column I code 25600. 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 93010 billed for date of service September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37185 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 37185. You say that the service at issue has been billed correctly. 
The Plan denied your request. The Plan says the available records do not support the service 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 37185 is: Primary percutaneous transluminal mechanical 
thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the 
same vascular family (List separately in addition to code for primary mechanical thrombectomy procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 37185. Our reviewer says that procedure 
code 37185 does not meet criteria for payment. Our reviewer found that the procedure report does not include 
enough information to confirm a thrombectomy has been performed, and this procedure is not documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 37185 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 37185 billed for date of service October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73630 billed for date of service December 
27, 2021. 
 
You asked the Plan to pay for the billed services. You say that the notes support the codes billed. The Plan 
denied your request. The Plan says the service is inclusive to the main procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 73630 is radiologic examination, foot; complete, 
minimum of 3 views. We find that CPT code 73630 was an integral part of the foot procedure provided to the 
enrollee. Code 73630 is not separately reportable in this case. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 73630 billed for date of service December 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an increase in therapy can help the enrollees overall 
health. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollee's needs can be me in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says they will continue to cover medically 
necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to an 
alternate level of care (such as a skilled nursing facility), or until the clinical circumstances change such that 
LTACH may be reconsidered. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IG-IMRT with three (3) fractions (G6015, 77014x3). 
 
You asked the Plan to pre-approve IG-IMRT. You say that treatment is medically necessary for the enrollee. 
The Plan denied your request. The Plan says up to 45 fractions of IG-IMRT is reasonable and necessary in any 
stage of localized prostate cancer. Up to 48 would exceed acceptable standards. The request for additional 
fractions is not approved. 
 
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 IG-IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for prostate cancer, NCCN guidelines offer as preferred dose fractionations is 3 Gy x 20, 2.7 
Gy x 26 and 2.5 Gy x 28. Conventional fractionation remains an acceptable alternative 1.8-2 Gy for 37-45 
fractions. In men with intermediate-risk prostate cancer receiving EBRT to the prostate with or without 
radiation to the seminal vesicles, moderate hypofractionation should be offered. The issue is the 
appropriateness of 48 fractions vs. 45 fractions (neither of which are preferred over moderate 
hypofractionation). Treatment with more fractions is costlier, which is the root of the dispute. 45 fractions in 
considered acceptable (albeit not preferable) by NCCN guidelines and ASTRO, ASCO, and AUA Evidence-
Based Guideline - with the expert guidelines acknowledging some limitations in the data.  There is no 
plausible explanation for why 3 additional fractions would be needed for this enrollee with low-risk prostate 
cancer.  If there is a plan to escalate the dose beyond 81 Gy that could readily be accomplished with dose 
painting IMRT to deliver slightly more dose and maintain acceptable risk of toxicity.  The decision is 
unfavorable as 48 fractions is not a standard of care approach, and the appeal does not address why it would be 
necessary or provide any evidence to support that treatment. The LCD does not apply and based on standard 
medical necessity criteria the criteria are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IG-IMRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IG-IMRT with three (3) fractions (G6015, 77014x3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need both physical and occupational 
therapy. The Plan denied your request. The Plan says your records do not show that you will require extended 
hospital level care for another 25 days, when you are ready to leave the hospital, you can safely receive this 
care in another setting, a skilled nursing facility (SNF). 
 
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 the records indicates that you have ongoing acute medical issues and still requires 
acute care services and you are continuing to receive currently and these have not been denied.  
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 care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizers purchased on March 12, 2022. 
 
You asked the Plan to pay for these services. You say that you purchased six nebulizers to save on shipping 
charges. The Plan denied your request. The Plan says one nebulizer is approved and the other five are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that the usual maximum frequency of replacement for a 
nebulizer is one every six months.  
 
We looked at the file and Medicare rules. The file shows that you purchased six nebulizers. The Plan has 
agreed to cover one nebulizer. The five further nebulizers exceed the usual maximum replacement amount and 
are not covered. Therefore, we decided that the Plan does not have to pay for the nebulizers purchased on 
March 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that you wanted to see this specific 
provider because they are closer to you. The Plan denied your request. The Plan says physical therapy services 
are available in network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee to progress and regain function. You say that this is the only option to give the enrollee a chance for an 
optimal outcome. The Plan denied your request. The Plan says the enrollee could discharge to a lower level of 
care. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you feel that you qualify for this program 
given your medical history and current diagnoses. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).