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

 
We decided that the Plan does not have to pre-approve Lupron (leuprolide acetate) injections. 
 
You asked the Plan to pre-approve the Lupron injections. You say that it is felt this drug should be approved 
due to medical necessity. The Plan denied your request. The Plan says there is no evidence that a trial of the 
preferred drugs would be less effective or cause adverse reactions. 
 
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 the Lupron injections. Our reviewer 
says that the requested drug is not considered medically necessary based on step therapy rules. Our physician 
reviewer found the enrollee has a diagnosis of malignant neoplasm of the prostate. The case file does not 
contain documentation of trial and failure of Eligard or Firmagon, the preferred agents. The documentation 
does not support that Eligard or Firmagon would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Lupron injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Lupron (leuprolide acetate) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for acupuncture treatment provided from  
August 27, 2021, through October 21, 2021. 
 
You asked the Plan to reimburse you for acupuncture treatment. The Plan denied your request. The Plan says 
our members may obtain services from any in-network acupuncturist. However, you received services from an 
out-of-network provider and you are not eligible for the supplemental benefit. 
 
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 reimburse you 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to reimburse you for these services. 
Therefore, we decided that the Plan does not have to reimburse you for acupuncture treatment provided from 
August 27, 2021, through October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit you provided on October 18, 2021. 
 
You asked the Plan to pay for a new patient office visit. The Plan denied your request. The Plan says clinical 
notes were not provided for the billing code of 99203- office /outpatient visit, to support the service rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a new patient office visit you provided 
on October 18, 2021 have been met. The file shows that medical records were not provided for review.  
 Therefore, we decided that the Plan does not have to pay for a new patient office visit you provided on 
October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cast application (29075) provided on January 4, 2022. 
 
You asked the Plan to pay for the cast application (29075). You say that the attached documentation supports 
the billed charges. You say that the documentation should be reviewed, and the claim reprocessed for payment. 
The Plan denied your request. The Plan says CPT codes 25600 and 99203 have been overturned. The Plan also 
says CPT code 29075 is inclusive to CPT code 25600 and not separately payable. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 29075 
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 the cast application (29075) provided on January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
November 10, 2021, to November 13, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that this stay was not your 
fault, it happened the night after you received the colonoscopy. The Plan denied your request. The Plan says 
you were charged the correct cost sharing amount. 
 
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 $295 
copayment each day for days 1 to 6 for Medicare-covered hospital care.  
 
You have been asked to pay a total of $885 in copayments for 3 days for inpatient hospital services ($295 
copayment x 3 days = $885). Inpatient hospital services fall within the inpatient hospital care benefit category. 
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 copayment for inpatient hospital services provided from November 10, 
2021, to November 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87653, 87798) provided on February 21, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87481, 87653, 87798) provided on February 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service January 5, 
2022. 
 You asked the Plan to pay for procedure code 72170. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 72170 is bundled into payment for 
code 73502. 
 
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 72170 
is a column II code to column I code 73502. 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 72170 billed for date of service January 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (96372) provided December 27, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is included in another procedure billed on the same 
date. 
 
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 CPT code 96372 is not supported in the medical record. Specifically, code 96372is included in 
code 10061 which was billed on the same day. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services (96372) provided December 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9366) provided from November 4, 
2021, through November 10, 2021. 
 
You asked the Plan to pay for home infusion therapy (S9366). You say that you are a contract provider that 
falls under in-network status for services. You say that the claim should be reprocessed under the correct 
network status. The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes. 
 
  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 CPT code S9366 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9366 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy (S9366) have not been met. Therefore, we decided that the Plan does not 
have to pay for home infusion therapy (S9366) provided from November 4, 2021, through November 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 20, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $200 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $200 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. 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 copayment for 
ambulance transportation provided on March 20, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy provided to the enrollee on February 11, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that procedure code 29823-59-LT is not supported by the medical records submitted. 
 
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 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 the services. Our reviewer says that the services at issue in 
this case Our reviewer found the enrollee was being treated for strain of muscle, fascia, and tendon of long 
head of biceps, left arm; complete rotator cuff tear or rupture of left shoulder; and superior glenoid lesion of the 
left shoulder. She underwent a left shoulder arthroscopy with extensive debridement, subacromial 
decompression, biceps tenodesis, rotator cuff repair, and removal of deep implants on 2/11/22. The CPT code 
29823 was supported as the procedure notes an extensive debridement was performed of the labrum, cartilage, 
and undersurface of the rotator cuff. Therefore, the records do support that CPT 29823: arthroscopy, shoulder, 
surgical: debridement, extensive, 3 or more discrete structures (e.g, humeral bone, humeral articular cartilage, 
glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, 
articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])- was 
rendered in this case. 
 
We looked at this coder'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 
surgical shoulder arthroscopy provided to the enrollee on February 11, 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 injections (J2001) provided November 24, 2021. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed shares a bundled relationship with another code 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, we have confirmed that code J2001 has a bundled relationship with code 20611. 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 injections (J2001) provided November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (0037U) provided February 15, 2022. 
 
You asked the Plan to pre-approve the genetic testing. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include FANCC gene testing are 
statutorily excluded from coverage. 
 
We looked at the file and Medicare rules. This panel included FANCC gene testing and is non-covered. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve genetic testing (0037U) provided February 
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical facet joint radiofrequency ablation procedure 
(CPT code 64633). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the enrollee did not have an adequate response to two diagnostic MBBs. 
 
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 you did not have a significant relief from the diagnostic block, therefore the C2-C3 RFA is 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical facet joint radiofrequency ablation procedure (CPT code 64633).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 an office visit provided on January 4, 2022, by an 
out-of-network (OON) provider.
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 pay for a portable oxygen concentrator (E1392) provided December 
15, 2021. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that this concentrator was medically 
necessary and you did not want to deal with the plan's rental supplier. The Plan denied your request. The Plan 
says purchased oxygen equipment is non-covered. The enrollee was approved for a rented oxygen concentrator. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. 
 
We looked at the file and Medicare rules. The portable oxygen concentrator was purchased. Based on this 
information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been 
met. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) 
provided December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve capsule endoscopy and small bowel endoscopy. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has stomach pain, nausea, and reflux 
symptoms. The Plan denied your request. The Plan says it is considered experimental and investigational for 
evaluation of stomach pain. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical appropriateness and necessity for wireless capsule endoscopy is not demonstrated 
by the enrollee's provided record. Indeed, the likelihood of slow gastrointestinal: (GI) transit in this enrollee 
with chronic constipation may reduce the clinical utility of the device in the provider's setting. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve capsule endoscopy and small bowel endoscopy.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a laparoscopic/robotic simple prostatectomy for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that there is not enough medical proof that shows the safety and/or 
success or artery embolization when used for this reason. 
 
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 pre-approve these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The enrollee has urinary 
retention due to benign prostatic hyperplasia (BPH). The enrollee's prostate size is 288 cc by ultrasound. 
Cystoscopy shows trilobar obstructive BPH. Our physician reviewer found that the enrollee's condition meets 
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 been met. Therefore, we decided that the Plan has to pre-
approve a laparoscopic/robotic simple prostatectomy for the enrollee.  
 
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.