Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subarachnoid injection without imaging guidance 
(62320), provided on November 1, 2021. 
 
You asked the Plan to pay for the subarachnoid injection. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this service is experimental. 
 
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 pay for the subarachnoid injection. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not contain sufficient information in the medical records submitted. In addition, the records submitted were not dated and not signed. 
 
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 subarachnoid injection have not been met. Therefore, we decided that the 
Plan does not have to pay for the subarachnoid injection without imaging guidance (62320), provided on 
November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve acupuncture services. You say that you believe this provider is approved for 
Medicare payment. The Plan denied your request. The Plan says there are in-network providers available to 
provide the care you need. 
 
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 
acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that HBOT is covered for specific indications only. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
you do not have a condition for which HBOT is covered. Our physician reviewer found you have a diagnosis of 
left lower extremity traumatic wound and diabetes. The provider indicates that you developed this ulcer 
following a fall in May of 2021. You have been treated with a wound vacuum with some improvement. You 
were recently placed on antibiotics for wound infection in February of 2022. You do not have a wound that has 
failed 30 days of standard wound care and no program payment may be made for HBOT used to treat 
cutaneous ulcers or chronic peripheral vascular insufficiency. The criteria for coverage are not met and the 
HBOT is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), of diagnostic or therapeutic 
substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with 
imaging guidance (ie, fluoroscopy or CT) (CPT code 62323). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 service. Our physician reviewer 
found the previous epidural steroid injection did not provide at least 50% pain relief for at least three (3) 
months. The review has determined that the medical records provided do not meet the requirements listed in 
the LCD for Medicare coverage. 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, 
opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or 
CT) (CPT code 62323).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic mammography, including CAD when performed; bilateral 
(CPT code 77066) and diagnostic digital breast tomosynthesis; bilateral (CPT code 77062) provided on 
November 16, 2021. 
 
You asked the Plan to pay for the services. You say that the enrollee has a history of lower inner quad left 
breast cancer with status post lumpectomy. You state the medical records and mammogram reports will support 
the need for follow-up. The Plan denied your request. The Plan says that the diagnosis is inconsistent with the 
procedure. 
 
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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the CPT manual advises to use both codes 77062 and 77066 when diagnostic mammography, 
CAD and tomosynthesis are done at the same sitting. Coding was proper and should be reimbursed. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
diagnostic mammography, including CAD when performed; bilateral (CPT code 77066) and diagnostic digital 
breast tomosynthesis; bilateral (CPT code 77062) provided on November 16, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection. 
 
You asked the Plan to pre-approve a platelet rich plasma injection. You say that the service is medically 
necessary. The Plan denied your request. The Plan says Platelet Rich Plasma injections are considered not 
medically reasonable and necessary for any use outside of the National Coverage Determination (NCD) 270.3 
Blood-Derived Products for Chronic Non-Healing Wound. This request is not for a chronic non-healing 
wound. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a platelet rich plasma injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a platelet rich plasma injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy provided to the enrollee on 
August 15, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this testing cannot be approved, as it 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee had metastatic prostate cancer. He had a recent biopsy for which Tempus xT tumor testing 
was ordered on. He is currently being treated with Casodex and Lupron. The enrollee does not meet the criteria 
for coverage. The review has determined that the services at issue in this case were not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Tempus xF liquid biopsy provided to the enrollee on August 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation One testing provided on November 26, 2021. 
 
You asked the Plan to pay for the Foundation One testing. You say that the testing was medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for authorization 
and the testing is considered 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 pay for the Foundation One testing. Our reviewer 
says that the enrollee does not meet Medicare guidelines for authorization and the testing is considered not 
medically necessary. Our physician reviewer found based on the medical records provided there is no 
documentation that the enrollee meets all of the above National Coverage Determination (NCD): Next 
Generation Sequencing (NGS) (90.2) criteria for the provided Foundation One genetic testing. Provided 
records do not document that the enrollee has either recurrent, relapsed, refractory, metastatic, or advanced 
stage III or IV cancer; has not been previously tested with the same test using NGS for the same cancer genetic 
content, and decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
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 Foundation One testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Foundation One testing provided on November 26, 2021.
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 medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 based on the provided records the patient appears to be more stable and improving 
and should only require short-term additional acute care services that can safely be administered at the current 
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 care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wig purchased on December 1, 2021. 
 
You asked the Plan to pre-approve the wig. You say that you would like reconsideration because this wig was 
prescribed by your oncologist following hair loss due to chemotherapy. The Plan denied your request. The Plan 
says this item is excluded from your plan benefits. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve the wig 
purchased on December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hospital outpatient clinic visits  
(G0463 x 2), the ultrasound of the breast (76642), the positron emission tomography (PET) scan (78815), the 
laboratory services (80048, 82962), and the routine venipuncture (36415) provided from April 8, 2021, through 
June 28, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
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 20% coinsurance for services you get in the 
outpatient department of a hospital, except for emergency care, observation services, laboratory services 
associated with dialysis, mammogram, and colonoscopy. 
 
You have been asked to pay $911.57 (The Plans allowed amount of $4,557.85 x 20% coinsurance) for the 
outpatient hospital services provided. This includes the Plans allowed amount of $4,243.80 x 20% 
coinsurance=$848.76 for the services provided on April 8, 2021. This also includes the Plans allowed amount 
of $121.55 x 20% coinsurance=$24.31 for the service provided on June 23, 2021. Additionally, this includes 
the Plans allowed amount of $192.50 x 20% coinsurance=$38.50 for the service provided on June 28, 2021. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the hospital outpatient clinic visits (G0463 x 2), the 
ultrasound of the breast (76642), the positron emission tomography (PET) scan (78815), the laboratory services 
(80048, 82962), and the routine venipuncture (36415) provided from April 8, 2021, through June 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. 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. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the documentation does not 
support that you require additional skilled nursing services to provide treatment that is medically necessary. 
The member does not require additional skilled nursing services to effectively provide treatment, care, and/or 
services in order to improve your condition, perform a maintenance program to maintain your condition and/or 
prevent deterioration. The requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on August 10, 2021. 
 
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 99152 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 99152 is moderate sedation services by other qualified 
health care professional requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
the first 15 minutes of an independent trained observer to monitor the patient's level of consciousness and 
physiological status. 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 moderate sedation services 
rendered on August 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous immunoglobin (IVIG) (J1569). 
 
You asked the Plan to pre-approve IVIG. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 IVIG. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found IVIG is not considered the standard of 
care for the enrollee's condition. The reviewer found that the requested use of IVIG is not FDA-approved for 
the enrollees diagnosis. The reviewer also found that the requested use is not supported by one of the major 
drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IVIG have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intravenous immunoglobin (IVIG) (J1569).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aerosol mask and nondisposable nebulizer administration 
set rendered on July 12, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded.  
 
We looked at the file and Medicare rules. Billed procedure codes A7005 and A7015 have a status indicator of 
X and are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the aerosol 
mask and nondisposable nebulizer administration set rendered on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 21, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
 
 We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on March 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that the services performed were distinct. The 
Plan denied your request. The Plan says the claim is a duplicate. 
 
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 looked at the file and the rules. We find that an additional service for CPT code 74018 is not supported in 
the medical record. The records provided do not show that more than one x-ray was provided. The x-ray 
services at issue were billed and paid for by the Plan on a previous claim. 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 x-ray services provided on March 29, 2021.