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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 May 11, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic Body Radiation Therapy (SBRT.) 
 
You asked the Plan to pre-approve SBRT. You say that the clinical information provided supports the need for 
SBRT. The Plan denied your request. The Plan says that the enrollee does not have low or intermediate risk 
prostate cancer. The Plan says that the enrollee did not have a biopsy to confirm that there was 
residual/recurrent disease within the enrollee's prostate gland. 
 
The Plan follows Medicare rules. Medicare rules say that SBRT will be considered medically reasonable and 
necessary for tumors arising in or near previously irradiated regions when a high level of precision and 
accuracy is required to minimize the risk of injury to surrounding normal tissues. 
 
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 SBRT. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the enrollee had magnetic resonance 
imaging (MRI) abnormality seen on a June 9, 2021, MRI scan, a positron emission tomography (PET) scan 
showing increased activity in the prostate gland and no other sites of disease, an elevated prostate-specific 
antigen (PSA) and an Eastern Cooperative Oncology Group (ECOG) performance status of 1. He has slowed 
urinary stream, but no records indicate obstruction of urinary flow. This enrollees treatment is not for 
upfront/initial therapy, but rather for recurrence. While this enrollee does not have biopsy recurrence, the PET 
scan findings coupled with the rising PSA are sufficient to diagnosed recurrence. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic Body Radiation Therapy (SBRT.)  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s) (L8702). 
 
You asked the Plan to pre-approve MyoPro orthosis device. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says there is insufficient evidence in the literature that the 
MyoPro orthosis will improve the long-term outcomes for upper extremity weakness and hemiparesis. There is 
no documentation the enrollee is enrolled in a clinical trial. The requested device is not medically necessary. 
 
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 MyoPro orthosis device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found clinical documentation shows that the enrollee has functional impairments and that a 
myoelectric orthosis can potentially help patients with neurological weakness however it does not show how 
the enrollee would specifically benefit from a myoelectric (improved functional outcome with a specific ADL) 
or a reasonable functional improvement related to the use of a myoelectric orthosis as opposed to a custom 
mechanical orthosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro orthosis device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, 
finger, single or double upright(s) (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoes (L3216) and custom orthotics (L3010). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the items at issue do not meet Medicare criteria for 
coverage. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that the enrollee does not meet Medicare criteria for coverage of the requested orthopedic 
footwear. Specifically, the type of orthopedic inserts requested are only covered when they are an integral part 
of a covered brace and medically necessary for the proper functioning of that brace.  Additionally, the custom shoes requested in this case are denied by Medicare as non-covered. Therefore, we 
decided that the Plan does not have to pre-approve custom shoes (L3216) and custom orthotics (L3010).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for intraoral procedures, including biopsy; not otherwise 
specified (CPT 00170) provided on April 28, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that the anesthesia services were medically 
necessary and billed with the correct codes. The Plan denied your request. The Plan says that the anesthesia 
services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for anesthesia services. Our reviewer says that 
the anesthesia services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that according to Medicare dental coverage guidelines: "Currently, Medicare will pay for dental services 
that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental 
injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw." 
 
The CPT code billed for the anesthesia services provided was appropriate. The enrollee, in this case, required 
the intraoral procedure required for pre-radiation clearance. The records submitted support the use of this code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia services have been met. Therefore, we decided that the Plan has to 
pay for anesthesia for intraoral procedures, including biopsy; not otherwise specified (CPT 00170) provided on 
April 28, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the perfusion services provided on April 19, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services are the standard of care for the 
enrollee's surgical procedure. The Plan denied your request. The Plan says the codes are included in the 
payment made to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
The file shows that the enrollee was an inpatient at the time the services were provided. The facility must 
furnish all necessary covered services to the beneficiary either directly or under arrangements made with 
outside providers.  This service was provided via arrangement of the facility. Payment for this service would have been included 
under the facility claim. Payment to you for this service is the responsibility of the facility. 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 the perfusion services provided on April 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion services provided on February 18, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the records 
do not support the number of units 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 B4185 is parenteral nutrition solution, not otherwise 
specified, 10 grams lipids. We find that 3 units of CPT code B4185 is not supported in the medical record. 
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 the infusion services provided on February 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intrauterine device (IUD). 
 
You asked the Plan to pre-approve an IUD. You say that the requested service is a medical necessity for you. 
The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that endometrial hyperplasia treatment with intrauterine 
device is covered when the criteria listed in the Medicare rules section of this letter have been met. 
 
We looked at the file and Medicare rules. The available medical records document that you are being treated 
for endometrial hyperplasia. The medical records do not document abnormal uterine bleeding. Based on this 
information, we decided that Medicare rules for coverage of an IUD have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an intrauterine device (IUD).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
is currently unstable for transfer to an LTACH. 
 
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. The patient 
appears to be stable and improving and should only require short-term additional acute care services that can 
safely be administered at the current facility until more stable and appropriate for a lower level of care. The 
patient does not require services at the LTACH that are not already available at the current facility. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that there is no one in-network that 
can provide the service that the enrollee needs. The Plan denied your request. The Plan says the requested 
provider is an OON provider and they have confirmed that there are in-network providers available that 
provide the same quality of service as the OON provider does. 
 
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 
the physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70460 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 70460. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70460 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 70460 
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 70460 billed for date of service May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing services provided on March 28, 2022. 
 
You asked the Plan to pay for the services provided. You say that the testing is used to help determine the best 
treatment option. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the panel testing services provided on March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management service provided on May 14, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code 99232 was not billed with a modifier suitable for payment. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the evaluation and management service provided on May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) services. 
 
You asked the Plan to pre-approve HBOT services. You say that the enrollee has a diabetic foot ulcer and 
further delay of the requested treatment should be avoided. The Plan denied your request. The Plan says the 
enrollee's wounds are not Wagner grade III or higher and magnetic resonance imaging did not show 
osteomyelitis. The Plan says that no debridements have been done to remove the devitalized tissue and the 
enrollee has been non-compliant with wound care. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for HBOT is limited to certain conditions. 
 
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 HBOT services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee has a chronic diabetic 
foot ulcer that was reported to have reopened. X-ray showed no frank lytic changes to suggest osteomyelitis, 
and magnetic resonance imaging (MRI) from May of 2022 showed "possible osteomyelitis" but not definitive evidence of such, and no more recent MRI was performed. The enrollee's wounds are not Wagner grade III or 
higher and there is no recent MRI showing osteomyelitis. No debridements have been done to remove the 
devitalized tissue according to the documentation provided, and the enrollee has been non-compliant with 
wound 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 HBOT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral nutritional product provided by a participating 
provider. 
 
You asked the Plan to pre-approve an oral nutritional product. You say that this nutritional product is medically 
necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
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 pre-approve an 
oral nutritional product provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this device is medically necessary for your 
lower back and feet pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional transportation trips. 
 
You asked the Plan to pre-approve 2 additional transportation trips. You say that you are disabled and have no 
car to get to appointments you need to get surgery. The Plan denied your request. The Plan says only 10 one-
way trips are covered every year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 2 additional transportation trips.