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

 
We decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography (ERCP) 
(43274) and endoscopic catheterization of the biliary ductal system (74328) provided on February 10, 2022. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim was not billed appropriately per 
Medicare coding rules. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Based on this 
information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, 
we decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography (ERCP) 
(43274) and endoscopic catheterization of the biliary ductal system (74328) provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on December 23, 2021. 
 
You asked the Plan to pay for the testing services. You say that the service denied in error. The Plan denied 
your request. The Plan says predictive screening testing is not a Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. We find that the testing at issue is not supported in the medical record. 
Specifically, there are insufficient records to show the reasoning for the testing. There are no records to show 
that the results will impact clinical management. Medicare does not cover this testing for screening services. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on December 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued SNF services after July 13, 2022. 
 
You asked the Plan to pay for continued SNF. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 8, 2022, to July 
14, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for continued SNF services after July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an ankle-foot orthosis (L1970). 
 
You asked the Plan to pre-approve an ankle-foot orthosis. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for 
coverage of the requested item have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that AFO are covered for ambulatory beneficiaries with 
weakness or deformity of the foot and ankle, who: 
1. Require stabilization for medical reasons, and, 
2. Have the potential to benefit functionally. 
 
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 ankle-foot orthosis. Our reviewer 
says that the requested item is medically reasonable and necessary in this case. Our physician reviewer found 
that the available clinical information from the podiatrist states that the enrollee requires a custom AFO due to 
eversion/inversion impairment along with foot drop. The clinical information also discusses the functional 
improvements related to the requested custom AFO. 
 
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 ankle-foot orthosis have been met. Therefore, we decided that the Plan has to 
pre-approve an ankle-foot orthosis (L1970).  
 
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 pre-approve a computed tomography (CT) colonography (74263). 
 
You asked the Plan to pre-approve a CT colonography. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested study is not covered for screening 
purposes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-
approve a computed tomography (CT) colonography (74263).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion/specialty drug administration services 
coded 99601 and 99602 provided on December 18, 2021. 
 
You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not 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. 
 
We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, these two 
codes have a status code of "I". This means that these codes are not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment of these services. Based on this information, we decided that 
Medicare rules for coverage of the home infusion/specialty drug administration services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration 
services coded 99601 and 99602 provided on December 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Multianalyte Assays with Algorithmic Analyses (81539) 
provided February 10, 2022 
 
You asked the Plan to pay for the laboratory services. You say that the doctor ordered the 4Kscore test as a safe 
and effective method to aid in evaluating the need for a prostate biopsy for the enrollee. The Plan denied your 
request. The Plan says the Medicare criteria for medical necessity is not met as the enrollee does not have a 
PSA within the range of 3-10. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show the enrollee has a PSA of 1.7-2.0 and is less than 
75 years old. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for Multianalyte Assays with 
Algorithmic Analyses (81539) provided February 10, 2022
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 insufficient information indicating that the enrollee has the ability and 
endurance to participate in this level of intensive therapy. There is also insufficient documentation indicating 
that the enrollee would be able to receive the full benefit from intensive therapies given that her baseline and 
current functional levels remain unchanged, and she has not had an acute change in function. The 
documentation does support a need for physical and/or occupational therapy, but there is no documented need 
for an intensive, multi-disciplinary rehabilitation program. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (11102, 11103, 17003, 17000) provided on 
December 10, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled.  
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 codes 
11102, 11103, and 17003 are column II codes to column I code 17110. We have also confirmed that code 
17000 is a column II code to column I code 11102. 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 services (11102, 11103, 17003, 17000) provided on 
December 10, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a High Intensity Focused Ultrasound (HIFU) (55880). 
 
You asked the Plan to pre-approve a HIFU. You say that the service at issue is medically necessary. The Plan 
denied your request. The Plan says that the requested service 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 a HIFU. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is an excellent candidate for primary HIFU treatment. HIFU treatment of the 
prostate is neither experimental nor investigational. HIFU was approved by the Food and Drug Administration 
for prostate gland ablation on October 9, 2015. HIFU of the prostate (CPT 55880) has Medicare coverage as of 
July 1, 2017. Numerous clinical studies have demonstrated treatment efficacy that is comparable to surgery or 
radiation but with a much lower risk of side effects such as impotence, incontinence and bowel injury. The 
requested services can be considered medically reasonable and necessary 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 a HIFU have been met. Therefore, we decided that the Plan has to pre-approve a 
High Intensity Focused Ultrasound (HIFU) (55880).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gonioscopy (92020) provided on September 22, 2021. 
 
You asked the Plan to pay for the gonioscopy (92020). You say that the claim should be processed with the 
supporting documentation. The Plan denied your request. The Plan says procedure code 65855 has been 
overturned. The Plan also says procedure code 92020 was not billed with an appropriate modifier to bypass the 
code edit. 
  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 92020 
is a column II code to column I code 65855. 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 gonioscopy (92020) provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine vision care services on January 18, 2022. 
 
You asked the Plan to pay for routine vision care. You say that you paid a $45 copay and this should have been 
covered. The Plan denied your request. The Plan says the denial of payment for these services is correct. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine vision care up to a $75 allowance once per calendar year. 
 
We looked at the file and the Plan's rules. The Plan paid the full $75 allowance for these services. You are 
responsible for the charges beyond this allowance. Based on this information, we decided that the Plan's rules 
for coverage of routine vision care have not been met. Therefore, we decided that the Plan does not have to pay 
for routine vision care services on January 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from January 11, 2022, 
through January 13, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided in this case are not among the types which are 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered 
drugs provided from January 11, 2022, through January 13, 2022.  Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (88365) provided on July 23, 2021 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, we have confirmed that code 88365 is a column II code to column I code 88377. 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 services (88365) provided on July 23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory and infusion treatments to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve laboratory and infusion treatments. You say that you sometimes have to 
visit the emergency room to receive infusion treatments and sometimes spend hours there. You say that you 
feel the Plan should provide the same benefit as dialysis. The Plan denied your request. The Plan says when 
you have an emergency medical condition, we cover emergency you receive from Plan providers or Non-Plan 
providers anywhere in the world. 
 
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 
laboratory and infusion treatments to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not 
tried an oral bisphosphonate and zoledronic acid. 
 
 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 Prolia. Our physician reviewer found 
that the enrollee has age-related osteoporosis without current pathological fracture. The Plan requires a trial of 
an oral bisphosphonate and zoledronic acid before they will approve the requested drug, Prolia. The enrollee 
has dementia and has difficulty taking pills, so an oral bisphosphonate does not appear appropriate for her. 
Records also report a prior trial of zoledronic acid, but there is no indication that the enrollee failed or had 
intolerable adverse effects to the zoledronic acid. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that the enrollee needs this due to chronic fatigue 
dyspnea. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because there is no documentation that the enrollee meets the clinical requirements for Reblozyl. 
 
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 Reblozyl. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Reblozyl. Our physician reviewer found 
there is no documentation of prior transfusions. Reblozyl (luspatercept) is not indicated for use as a substitute 
for transfusions in patients who require immediate correction of anemia. The requested use of Reblozyl is not 
Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported 
by one of the major drug compendia or by clinical research that appears in a Medicare-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 Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Reblozyl.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for level IV surgical pathology, gross and microscopic 
examination (88305) provided December 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you did not know that the provider had 
opted out of Medicare. The Plan denied your request. The Plan says 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 no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for level IV 
surgical pathology, gross and microscopic examination (88305) provided December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a basic pneumatic compression device (E0651) from an 
out-of-network provider. 
 
You asked the Plan to pre-approve a basic pneumatic compression device (E0651). You say that you are 
appealing the denial. The Plan says they will cover a basic pneumatic compression device and accessories 
supplied by the in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. Therefore, we decided that the Plan does 
not have to pre-approve a basic pneumatic compression device (E0651) from an out-of-network provider but 
will cover the device from the in-network provider.