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

 
We decided that the Plan does not have to pre-approve Proton Beam Therapy for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that proton beam therapy has been shown to have 
lower toxicity than conventional radiation therapy. The Plan denied your request. The Plan says that Proton 
Beam treatment is not recommended for the treatment of prostate cancer. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is insufficient 
prospective, long-term clinical data available to determine whether or not proton beam radiation therapy (PBT) 
for prostate cancer is superior, inferior or equivalent to external beam radiation therapy, Intensity-modulated 
radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. The most recent AUA 
guidelines state that PBT offers no clinical advantage over other forms of definitive treatment. NCCN 
guidelines note that there lacks clear evidence to support a benefit or decrement to proton therapy over IMRT 
for either treatment efficacy or long-term toxicity. Firm conclusions regarding differences in toxicity or 
effectiveness of proton and photon therapy cannot be drawn because of the limitations of the available studies. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Proton Beam Therapy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a glycosylated hemoglobin test provided on May 14, 2021. 
 
You asked the Plan to pay for a glycosylated hemoglobin test. You say that according to our records the 
enrollee had an active coverage on the date of service and should not be held liable for any charges, except for 
contractual obligations. The Plan denied your request. The Plan says the glycosylated hemoglobin test is not a 
Medicare covered service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a glycosylated hemoglobin test, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for a glycosylated hemoglobin test provided on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted multianalyte assay with algorithmic analysis 
provided on March 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for unlisted multianalyte assay with algorithmic analysis. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered 
in an in-network facility. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for unlisted multianalyte assay with algorithmic 
analysis provided on March 24, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone 1.62% gel. 
 
You asked the Plan to pre-approve Testosterone 1.62% gel. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Testosterone 1.62% gel.  
 
 
 Benefits for Testosterone 1.62% gel may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF care. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely 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. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician's close 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or documented. The enrollee does 
not need therapy 3 hours a day, 5 days a week. While she would benefit from physical and occupational 
therapy, the enrollee's rehab needs can be safely provided in an alternate and low intensity setting. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on April 12, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that you were unaware that you needed a referral 
from your primary care physician to see a specialist. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the podiatry services provided on April 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on January 
19, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 8. This code was billed with a place of service of 22 (outpatient hospital). This means this code was billed with an incorrect place of service. Based on this information, we decided that 
Medicare rules for coverage of the blood smear services have not been met. Therefore, we decided that the Plan 
does not have to pay for the blood smear services coded 85060 provided on January 19, 2022.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 the enrollee by their own performance demonstrates they do not require intensive or 
complex rehabilitation and does not have medical needs that are barriers to their receiving rehabilitation at a 
lower level of 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee orthoses (L1843 and L1844). 
 
You asked the Plan to pre-approve the orthoses. You say that you would like to appeal the denial for the knee 
braces and the records should support the necessity for the requested knee braces. The Plan denied your 
request. The Plan says the request is not medically necessary because your records show you do not have recent 
injury or surgery or objective evidence of instability. 
 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 the orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee is a 61 year old male with a diagnosis of knee pain. The 
record sent by the provider indicates that he has chronic bilateral knee pain due to arthritis. The records do not 
demonstrate recent knee injury, knee surgery, or that instability of the knees was found on physical exam. 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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee orthoses (L1843 and L1844).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), bifocal lens (V2200), anti-reflective 
coating (V2750), and polycarbonate or equal lens (V2784) provided on April 5, 2022. 
 
You asked the Plan to pay for the glasses. You say that you would like the Plan to authorize payment for your 
glasses. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 5, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the glasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the frames (V2020), bifocal lens (V2200), anti-reflective coating 
(V2750), and polycarbonate or equal lens (V2784) provided on April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision, other benign lesion including margins, 
except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane (11440). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the growth is on your eyelid and you 
can look at it and it effects your side vision. The Plan denied your request. The Plan says the growth is not 
cancer and there is insufficient evidence that the requested service is 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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee states she is requesting removal of noncancer 
skin growth of face, ears, eyelids, nose, lips, or mouth, 0.5 cm. She stated the growth/ball is on her right eye, on 
the line of her eye towards the end of her eye line. She stated it is very irritating and when she looks to her side 
the growth is right there and can look at it. It effects side vision. There is no documentation indicating that the 
growth is cancer and there is insufficient evidence that the requested service is medically necessary. The review 
has determined that the items/services at issue in this case are 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the excision, other benign lesion including margins, except skin tag (unless listed 
elsewhere), face, ears, eyelids, nose, lips, mucous membrane (11440).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on February 28, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that the refractions should be covered because the 
refraction is done yearly to determine if you need corrective lens. The Plan denied your request. The Plan says the 
member does have supplemental vision care that covers one routine vision exam per year including eye 
refraction for eyeglasses/contact lenses. It was confirmed that the services received were not for a routine eye 
exam. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heel wedge (L3350). 
 
You asked the Plan to pre-approve a heel wedge. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says the requested 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 a heel wedge (L3350).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee does require treatment by multiple therapies, including physical therapy and occupational 
therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 
hours over seven consecutive days. The enrollee is minimum to moderate assistance with bed mobility and 
moderate to maximal assistance for transfers. The enrollee requires minimal assistance for upper body dressing 
and maximal assistance for lower body dressing. The enrollee has had a decline in their functional status from 
his baseline level of function and physical and occupational therapy documentation indicates that the enrollee 
can participate and benefit from therapy to improve their function. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hand surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you want to have this procedure 
performed by this provider because the in-network providers will not perform this specific procedure. The Plan 
denied your request. The Plan says the requested services can be provided by a network provider. 
 
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 
hand surgery to be provided by an out-of-network (OON) provider.