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

 
We decided that the Plan has to pay for Intensity Modulated Radiation Therapy (IMRT) (CPT G6015) provided 
on November 9, 2021. 
 
You asked the Plan to pay for IMRT. You say that IMRT was medically necessary. The Plan denied your 
request. The Plan says that IMRT is not considered medically necessary 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for IMRT. Our reviewer says that IMRT is 
medically necessary in this case. Our physician reviewer found in general, IMRT is not an experimental 
technique, but rather a radiation planning and delivery tool available to the radiation oncologist to better shape 
the radiation dose distribution, and therefore minimize the dose to normal structures. IMRT is a tool that 
clinicians can use when there is concern about sparing normal tissues from high dose exposure.  IMRT 
generally implies inverse planning algorithms, i.e. the physician determines radiation treatment parameters to 
maximize dose to the target and minimize dose to normal tissues, and the planning algorithm maximizes the 
adherence to these parameters by modifying the beam spatially and/or temporally. There are abundant data 
which support the use of IMRT with head and neck cancer. Conceding that the published data supporting need 
for IMRT for T1-2N0 glottic cancer are limited, IMRT would be within accepted standards of medical practice 
and therefore meet standard medical necessity criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pay for 
Intensity Modulated Radiation Therapy (IMRT) (CPT G6015) provided on November 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of unlisted neurological or neuromuscular 
diagnostic procedure provided to the enrollee on March 14, 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 the documentation received does not indicate that CPT 95999 was performed more than once for 
this date of service. 
 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 95999 is "Unlisted neurological or neuromuscular 
diagnostic procedure." 
 
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 were not supported by the medical records. Our reviewer found that the medical record provided do 
not include sufficient documentation to support billing more than 1 unit of 95999, therefore this additional unit 
of 95999 cannot be verified. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit of unlisted neurological or neuromuscular diagnostic procedure provided to 
the enrollee on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that the item is medically necessary. The 
Plan denied your request. The Plan says that the item is not medically necessary. 
 
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 an electronic connection. Our reviewer 
says that the requested items is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee cannot perform pressure relief independently due to weakness and skin breakdown 
and requires a power wheelchair with two power components, power tilt and power articulating center mount 
components for pressure relief and positioning. 
 
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 electronic connection have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection (E2311).  
 
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 an epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve an ESI. You say that the enrollee has not had a previous injection in this 
spinal area. You also say the previous approval was for a different area of the spine. The Plan denied your 
request. The Plan says the enrollee has chronic back pain, but the information sent does not show that they have 
had recent physical therapy for at least 4 weeks for the current area of back pain. The Plan also says the records 
do not show any change in the enrollee's muscle strength or reflexes that indicates pressure on a nerve. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs should be performed in conjunction with 
conservative treatments. 
 
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 ESI. Our physician reviewer found 
there is no documentation of recent conservative therapy. Our reviewer also found that the request is deemed 
not medically reasonable and necessary at this time. 
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI) (64483).
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. 
 
You asked the Plan to pre-approve IRF care. You say that acute inpatient rehabilitation is medically necessary 
for the enrollee. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient 
Rehabilitation setting have not been met. Medically necessary care may be provided safely in a different level 
of care. 
 
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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the enrollee meets criteria for coverage. 
The Plan denied your request. The Plan says there is not enough documentation to approve the requested 
service. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of proton beam therapy requires specific 
documentation as listed 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 proton beam therapy. Our reviewer says 
that the enrollee does not meet LCD criteria for coverage of proton beam therapy. Our physician reviewer 
found there is insufficient prospective, long-term clinical data available to determine whether or not proton 
beam radiation therapy 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. Recent 
data shows no significant differences in late (years one, two, and three) patient-reported toxicity outcomes 
between proton beam therapy and IMRT. The most recent assets under administration (AUA) and National 
Comprehensive Cancer Network (NCCN) guidelines state that PBT offers no clinical advantage over other 
forms of definitive treatment. Also, the records do not show that the enrollee is enrolled in a valid clinical trial. 
A prospective chart review is not considered a valid clinical trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 14301, 29515) provided 
to the enrollee on April 18, 2022. 
 
You asked the Plan to pay for the services. You say that additional payment should be made for this claim. The 
Plan denied your request. The Plan says the provider has been informed that the service has been billed 
incorrectly. 
 
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 the denied codes is: 
 
CPT 29515: 
 
Application of short leg splint (calf to foot) 
 
CPT 14301: 
 
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm 
 
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 were not supported by the medical records. Our reviewer found that in terms of CPT 14301, the 
operative report does not include enough documentation to confirm an adjacent tissue transfer was performed. 
In this case, measurement of excision and secondary defect are not documented, and therefore cannot be 
verified. In terms of CPT 29515, application of the splint would be inclusive to the global surgical CPT 
code. Therefore, this procedure cannot be verified, as was performed during therapeutic procedure. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 14301, 29515) provided to the enrollee on April 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that the enrollee has had a coronary calcium score 
performed in the past revealing a score of 846. You also say the enrollee does suffer from occasional dyspnea 
on exertion. The Plan denied your request. The Plan says this request cannot be approved because the enrollee 
does not meet the criteria for coverage. 
 
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 a TTE. Our reviewer says that the 
requested TTE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee has a history of an elevated coronary calcium score. Documentation at this time would not point to 
a change in status that would support the medical necessity of a repeat TTE. Our reviewer found that clinical 
guidelines do not support repeating a TTE with no intervening change in clinical status or new signs, 
symptoms, or physical findings. Our physician reviewer also found that there is no supportive evidence for the 
medical necessity of repeat TTE in this 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 a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE) (93306).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that living alone could cause more injuries with the 
navigation of daily activities. You say until you can gain any independence with your right arm, everyday tasks 
are next to impossible with the limited mobility. The Plan denied your request. The Plan says you do not meet 
the criteria for a SNF admission. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
whole body (78813). 
 
You asked the Plan to pre-approve a PET scan of the whole body. You say that the medical records specifically 
show prior imaging with noted pulmonary nodules greater than 8 millimeters. The Plan denied your request. 
The Plan says this request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 a PET scan of the whole body. Our 
reviewer says that a PET scan of the whole body is not reasonable and necessary for the enrollee. Our 
physician reviewer found the record indicates that the enrollee had a suspicious nodule on chest imaging. The 
record indicates that biopsy was performed and revealed a benign lesion. Our reviewer found that the record 
does not indicate the diagnosis of cancer. The elements of the coverage criteria are not satisfied. Our physician 
reviewer also found that the requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan of the whole body have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a positron emission tomography (PET) scan of the whole body (78813).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IV infusion hydration. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says fluids are able to be received through the mouth or tube feeding through the nose or 
stomach. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there is no specific clinical rationale for the requested services. There are no laboratories 
provided to evaluate her current renal status. 
 
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 IV infusion hydration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulator (TENS) unit 
supplies provided on September 3, 2022. 
 
You asked the Plan to pay for TENS unit supplies. You say that this claim was billed in accordance with 
policy. The Plan denied your request. The Plan says there is no evidence to support the ordering provider 
ordered these supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of DMEPOS items requires proof of 
delivery.  
 
We looked at the file and Medicare rules. The record does not include valid proof of delivery for the item billed 
on this claim. Specifically, the delivery form does not include evidence of delivery to the enrollees specific 
address. Based on this information, we decided that Medicare rules for coverage of TENS unit supplies have 
not been met. Therefore, we decided that the Plan does not have to pay for transcutaneous electrical nerve 
stimulator (TENS) unit supplies provided on September 3, 2022.
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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of LTACH care is correct. 
 
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 the enrollee appears to be improving but is not yet stable and should only require 
short-term additional acute care services that can be safely provided at the current facility until appropriate for 
discharge to 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the drug was a medically necessary part of 
treatment. The Plan denied your request. The Plan says the service is included in the global surgery package. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is excluded from the physician fee schedule. These codes are for items and/or services that CMS chose to 
exclude from the fee schedule payment by regulation. No relative value units (RVUs) are shown, and no 
payment may be made under the fee schedule for these codes. 
 Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for date of 
service July 1, 2022.