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

 
We decided that the Plan does not have to pre-approve 10 fractions of 3D conformal radiation therapy. 
 
You asked the Plan to pre-approve 10 fractions of 3D conformal radiation therapy. You say that these radiation 
services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says 3D 
conformal radiation is not supported for the enrollee's condition in this case. 
 
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 10 fractions of 3D conformal radiation 
therapy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that for whole brain radiation (including prophylactic 
brain radiation), even when a computed tomography scan is used for treatment planning purposes, and when a 
3D dose matrix is generated for billing purposes, it is the accepted standard to bill 2D radiation and not 3D 
radiation. 
 
Generally, 3D radiation is necessary when the 2D radiation plan results in unacceptable normal tissue dose 
exposure and toxicity risks (uncommon with palliative treatment). It usually implies the need to spare normal tissues in a manner that cannot be achieved with 2D radiation.  
 
Even with 2D radiation, a computed tomography based plan can be obtained to calculate the cord dose. While 
one may argue that all (non intensity-modulated radiation therapy) whole brain radiation should be billed as 2D 
radiation, and also not necessarily true that if one is using a 2D field arrangement that 3D should not be 
billed even if using computed tomography for planning and/or MLC for field shaping, this is the accepted 
standard. Therefore, the need for 3D radiation has been substantiated in this case and that it would be within 
accepted standards of care to use 2D radiation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 fractions of 3D conformal radiation therapy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 10 fractions of 3D conformal radiation therapy.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
December 12, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that all the ER doctor did was give you 
medication and sent you on your way. You also say you expected to get an x-ray and for someone to look at 
your leg when you came in and could barely walk. 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 $90 
copayment for an emergency room visit.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$90 copayment for an ER visit. An ER visit falls within the Emergency 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 an emergency room (ER) visit provided on December 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on December 2, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the arthrocentesis, aspiration and/or 
injection of a major joint or bursa (20611 x 4) and the Hyaluronan or derivative, Euflexxa, for intra-articular 
injection, per dose (J7323 x 4) provided from January 8, 2021, through December 8, 2021. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
items/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 each Medicare-covered Part B drug. Additionally, you must pay a $45 copayment for 
outpatient surgery provided by a specialist, for each outpatient clinic visit.    
 
You have been asked to pay $292.14 ($72.96 +$73.06 +$73.06 + $73.06). This amount includes the Plan 
allowed amount of $140.31 x 20% coinsurance=$28.06 for the Medicare-covered Part B drug and a $45 
copayment for the outpatient surgery provided by a specialist on January 8, 2021, January 15, 2021, and 
January 22, 2021. Additionally, this amount includes the Plan allowed amount of $138.82 x 20% = $27.76 for 
the Medicare-covered Part B drug and a $45 copayment for the outpatient surgery provided by a specialist on 
December 8, 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 cost share for the arthrocentesis, aspiration 
and/or injection of a major joint or bursa (20611 x 4) and the Hyaluronan or derivative, Euflexxa, for intra-
articular injection, per dose (J7323 x 4) provided from January 8, 2021, through December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Prodigy Glucometer, Prodigy test strips, Prodigy control 
solution, TRUEplus lancets, and TRUEplus lancing device (E0607, A4253, A4256, A4258, A4259) provided 
July 21, 2020. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that the items were medically necessary. 
The Plan denied your request. The Plan says the brand is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Prodigy and TRUEplus are not covered brands under the plan 
contract. The records provided do not show why the enrollee could not use the plan preferred brands. Based on 
this information, we decided that Medicare rules for coverage of the diabetic testing supplies have not been met. Therefore, we decided that the Plan does not have to pay for a Prodigy Glucometer, Prodigy test strips, 
Prodigy control solution, TRUEplus lancets, and TRUEplus lancing device (E0607, A4253, A4256, A4258, 
A4259) provided July 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services performed by a qualified physical therapist in 
the home health or hospice setting (G0151) and the services performed by a qualified physical therapist 
assistant in the home health or hospice setting (G0157) rendered by the out-of-network (OON) provider from 
September 24, 2021, through October 23, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the services performed by a qualified physical therapist in the home health or 
hospice setting (G0151) and the services performed by a qualified physical therapist assistant in the home 
health or hospice setting (G0157) rendered by the out-of-network (OON) provider from September 24, 2021, 
through October 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81404, 81442, 81479) provided June 8, 2021. 
 
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 the documentation does not support the billed services. 
 
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 (81404, 81442, 81479) provided June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One injection to be provided by a provider that 
is not in your medical group. 
 
You asked the Plan to pre-approve the injection. You say that the provider you were referred to is not your 
PCP. You say that you have never seen him in that capacity. You say that you have an established rapport with 
the requested physician. You also say that you do not want to start all over again with a different physician. 
The Plan denied your request. The Plan says the service was denied correctly. 
 
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 affiliated with your Primary Care Physician (PCP) network. The 
record shows that your PCP referred you to a provider that is affiliated. 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 Synvisc-One injection to be provided by a provider that is not in your medical group.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from February 1, 2021, 
through November 10, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you are supplying the receipts that are 
necessary for payment. The Plan denied your request. The Plan says these claims are missing information 
required for payment. 
 
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 the chiropractic services provided from 
February 1, 2021, through November 10, 2021, have been met. Specifically, the Plan requested medical 
documentation to corroborate the services as they were billed. No medical records have been returned despite the Plans multiple outreaches. Therefore, we decided that the Plan does not have to pay for the chiropractic 
services provided from February 1, 2021, through November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency generated water vapor thermotherapy 
(53854). 
 
You asked the Plan to pre-approve radiofrequency generated water vapor thermotherapy. You say that the 
requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says 
medical necessity rules for the requested procedure have not been met.  
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 radiofrequency generated water vapor 
thermotherapy. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the records do not show that the enrollee is a poor 
candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease, pulmonary 
disease, etc.), or at high risk of bleeding. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency generated water vapor thermotherapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency generated water vapor 
thermotherapy (53854).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap (15378) 
provided on August 24, 2021. 
 
You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap (15378). You say that the 
rendering provider is out-of-network with the plan and is not obligated to accept the fee schedule. You say that 
additional payment should be made. The Plan denied your request. The Plan says procedure code 15738-59 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. 
 
In this case, the CPT Code Manual definition of code 15378 is muscle, myocutaneous, or fasciocutaneous flap; 
lower extremity. 
  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 muscle, myocutaneous, or fasciocutaneous flap (15378). 
Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. 
Our reviewer found that the operative report does not include enough documentation to support CPT coding 
guidelines for flaps. In this case, the recipient area is not documented. 
 
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 muscle, myocutaneous, or fasciocutaneous flap (15378) have not been met. 
Therefore, we decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap 
(15378) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an additional 39 units of the anesthesia services (00400) provided on 
June 29, 2021, to total 91 units. 
 
You asked the Plan to pay for an additional 39 units of code 00400. 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 
supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We looked at the file and Medicare rules. The file shows that there were two claims billed by the same 
provider. One claim billed 91 units of code 00400, which the Plan denied payment for. The second claim billed 
52 units of code 00400, which the Plan approved payment for. We find that a total of 91 units of CPT code 
00400 are supported in the medical record. The file shows that Plan has already paid 52 units of code 00400 to 
this provider. Therefore, we decided that the Plan has to pay for an additional 39 units of the anesthesia 
services (00400) provided on June 29, 2021, to total 91 units.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve residential treatment level of care. 
 
You asked the Plan to pre-approve residential treatment level of care. You say that you have been receiving 
outpatient treatment with no success. You say that your provider advised you would need to be inpatient along 
with therapy. You also say that when you are in the hospital, the stay and medical part are both paid for so this 
should be covered too. The Plan denied your request. The Plan says the care you have requested is not a 
Medicare covered service. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of residential treatment level of care have not been met. Specifically, the level of care and intensity of 
services differs between an inpatient and residential confinement. Residential treatment level of care is not a 
Medicare covered service. Therefore, we decided that the Plan does not have to pre-approve residential 
treatment level of care.
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 clinical documentation provided 
supports the need for LTACH care. The Plan denied your request. The Plan says LTACH care is not medically 
necessary. 
 
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 there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on 
October 5, 2021. 
 You asked the Plan to pay for genetic testing. You say that you provided medically necessary testing in good 
faith. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this 
screening testing is not covered by Medicare. 
 
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, genetic testing, was requested for screening purposes. Medicare does not cover 
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary 
cardiovascular screening panel testing provided on October 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hospice care services provided on September 14, 
2021. 
 
You asked the Plan to pre-approve the hospice care services. You say that you would like this claim 
reprocessed based on updated billing information you have submitted. The Plan denied your request. The Plan 
says this claim has not been billed correctly based on Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that hospices must report value code G8 when billing 
revenue codes 0655 and 0656. 
 
We looked at the file and Medicare rules. In this case, value code 61 has been reported along with revenue code 
0656. This is incorrect as according to Medicare rules value code G8 must be billed. Based on this information, 
we decided that Medicare rules for coverage of the hospice care services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the hospice care services provided on September 14, 2021.