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

 
We decided that the Plan does not have to pre-approve radiation treatment delivery. 
 
You asked the Plan to pre-approve radiation treatment delivery. You say that radiation treatment delivery is 
medically necessary. The Plan denied your request. The Plan says radiation treatment delivery 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 radiation treatment delivery. Our 
reviewer says that radiation treatment delivery is not considered medically reasonable and necessary in this 
case. Our physician reviewer found in general, this as a standard treatment for men undergoing androgen 
deprivation therapy (ADT) and treatment is supported by published evidence. However, for this enrollee, the 
last note describes treatment to the pelvis (for salvage radiation) and that the enrollee declined ADT. While 
this may have changed, there are no records describing him receiving ADT or describing the need for 
management of gynecomastia either as prophylactic treatment or therapeutic treatment. Thus, this decision is 
unfavorable as this radiation would not be needed (and outside standard of care) in men who do not undergo 
ADT. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiation treatment delivery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided on 
January 4, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you feel the cost of the drug should 
be covered. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 Part B drugs.  
 
You have been asked to pay $366.30, which is 20% of the allowed amount for the injection ($1,831.50 allowed 
amount x 20% coinsurance = $366.30). The injection falls within the Medicare Part B Prescription Drugs 
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 coinsurance for an aflibercept injection 
provided on January 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found clinical documentation states that you 
have poor participation in daily skilled therapy and able to safely transition to level of care with intermittent 
skilled services, thus continued daily skilled services in a skilled nursing facility is 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on January 20, 2022. 
 You asked the Plan to pay for outpatient hospital services. You say that this claim was billed appropriately and 
should be paid. The Plan denied your request. The Plan says G2023 was reported on this claim, but this code 
has a payment status indicator of "B", which means that it is not recognized by OPPS. According to I/OCE edit 
instructions, edit 62 applies in this case, and the whole claim is returned to the provider for correction. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that when a code with a 
status indicator of B is reported on an OPPS 13x bill type, then the whole claim is rejected and returned to 
the provider for correction. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient services have not been met. Specifically, this claim was billed with code G2023, which 
has a payment status indicator of B. That means that the claim is returned to the provider, and this line must 
be corrected before any part of this claim can be paid. Therefore, we decided that the Plan does not have to pay 
for outpatient hospital services provided on January 20, 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 SNF 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 the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve implantation of a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that the enrollee has tried all conservative 
treatments and this is medically necessary. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the enrollee has not had recent psychological evaluation to 
improve pain or any recent trials of physical therapy, or other treatment to help with pain. 
 
The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered if certain 
criteria are 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 spinal cord stimulator. Our reviewer 
says that the enrollee meets the Medicare criteria for a spinal cord stimulator. Our physician reviewer found the 
progress note documents that the enrollee has had pharmacologic trials, psychological therapy, physical 
therapy, and has seen a surgeon. This is a last-resort procedure after a successful stim-wave trial. This request 
is medically reasonable and 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 spinal cord stimulator have been met. Therefore, we decided that the Plan has to 
pre-approve implantation of a spinal cord stimulator.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti (CPT code Q5117), Carboplatin (J9045), 
Paclitaxel (J9267), Palonosetron (J2469), dexamethasone (J1100), and fosaprepitant (J1453). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for your 
treatment for endometrial cancer. The Plan denied your request. The Plan says the use of this drug/regimen is 
not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our physician reviewer 
found the requested use of the medication regimen is not Food and Drug Administration (FDA)-approved for 
the enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research 
that appears in a Centers for Medicare & Medicaid Services (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 the medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Kanjinti (CPT code Q5117), Carboplatin (J9045), Paclitaxel (J9267), Palonosetron 
(J2469), dexamethasone (J1100), and fosaprepitant (J1453).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor. 
 
 
You asked the Plan to pre-approve insertion, subcutaneous cardiac rhythm monitor. You say that insertion, 
subcutaneous cardiac rhythm monitor is medically necessary. The Plan denied your request. The Plan says 
insertion, subcutaneous cardiac rhythm monitor 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 insertion, subcutaneous cardiac rhythm 
monitor. Our reviewer says that insertion, subcutaneous cardiac rhythm monitor is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR.  In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollees clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion, subcutaneous cardiac rhythm monitor have not been met. Therefore, 
we decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676). 
 
You asked the Plan to pre-approve an intermittent limb compression device. 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 follows Medicare rules. Medicare rules say that a PCD coded as E0676 is used only for prevention of 
venous thrombosis. 
 
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 an intermittent limb compression 
device. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
review indicates that you are having back surgery August 19, 2022, and this machine is planned to be used to 
prevent blood clots. Your records say that you have a history of a left deep vein thrombosis (DVT) in 2016. 
Medicare's guidelines state: A PCD that provides intermittent limb compression for the purpose of prevention 
of venous thromboembolism (E0676) is a preventive service. Items that are used for a preventative service or 
function are excluded from coverage under the Medicare DME benefit. The review has determined that you do 
not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intermittent limb compression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found clinical information shows the enrollee would 
benefit from skilled nursing as there are medical monitoring needs. The enrollee is functioning beneath stated 
baseline thus would benefit from skilled therapy. Evaluating therapist recommend daily skilled services in an 
inpatient setting after discharge but documentation from PT and OT states that all functional tasks were 
completed at a supervision level and there is no clinical reasoning documented as to why the enrollee would 
require daily professional supervision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) purchased November 2, 2021. 
 
You asked the Plan to pay for the CPAP device. You say that your original CPAP machine quite operating and 
you had to purchase a replacement. It is medically necessity that you continue to utilize the CPAP every day. 
The Plan denied your request. The Plan says the item was purchased from a supplier who is not certified with 
Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the 
full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device (E0601) purchased November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like to appeal the denied 
services. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no approved authorization. 
  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 laboratory services provided on September 16, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis (L3916) provided April 11, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this claim met all of Medicare's DME LCD coverage 
criteria and the enrollree's primary care physician prescribed this brace within 6 months of the face to face visit. 
The Plan denied your request. The Plan says the records do not support the service billed. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have 
not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis (L3916) 
provided April 11, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81479) provided on December 14, 2021. 
 
You asked the Plan to pay for code 81479. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied payment for code 81479 stating that this one code was 
submitted on its own on a separate claim form from the other codes that were submitted on a different claim 
form performed on the same date of service. However, the Plan has provided no evidence that the provider 
billed additional codes beyond code 81479. Therefore, we decided that the Plan has to pay for the laboratory 
services (81479) provided on December 14, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomographic angiography 
(CTA) of the neck provided on March 10, 2022. 
 
You asked the Plan to reduce the copayment for the CTA. You say that your copayment should only be $40 or 
$90. 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 $250 
copayment for advanced imaging services, such as CT scans.  
 
You have been asked to pay a $250 copayment for the CTA. The CTA falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 reduce the copayment 
for a computed tomographic angiography (CTA) of the neck provided on March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy visits to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits to be provided by an out-of-network (OON) provider.