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

 
We decided that the Plan does not have to pay for the screening mammography, bilateral (2-view study of each 
breast), including computer-aided detection (CAD) when performed (77067) screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) (77063) provided January 
17, 2022. 
 
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date 
of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your 
request. The Plan says duplicate claim, original claim in process. 
 
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 find that CPT codes 77067-TC and 77063-TC are not supported in the medical record. 
Specifically, the records show that the Plan had paid for procedure codes 77067-TC and 77063-TC to another 
provider in the same group practice on check dated March 3, 2022. The records provided do not support that 
this service was rendered twice. Based on this information, we decided that Medicare rules for coverage of the 
diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the 
screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) 
when performed (77067) screening digital breast tomosynthesis, bilateral (List separately in addition to code 
for primary procedure) (77063) provided January 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia provided on August 1, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that the provider was certified on this date of service and 
eligible to perform anesthesia services. You say that the claim should be reconsidered for payment. The Plan 
denied your request. The Plan says that anesthesia codes are reimbursed to anesthesia providers only. 
 
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 has not provided a valid rationale for why the rendering provider type 
is not appropriate for anesthesia services. It is the burden of the Health Plan to substantiate their decision with 
evidence. In this case, their denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the anesthesia provided on August 1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on December 
6, 2021. 
 
You asked the Plan to pay for the services. You say that you longer have a spleen, and need these vaccines. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on 
December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased March 10, 2022, from an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the hearing aids purchased OON. You say that the hearing aids from this 
provider are less expensive. The Plan denied your request. The Plan says the hearing aids are not covered 
because they were purchased OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you see a provider in the Plans hearing network. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were purchased OON. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids purchased OON have not been 
met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased March 10, 2022, 
from an out-of-network (OON) provider.
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 enrollee needs close cardiac 
monitoring and while in the LTACH they will receive daily doctor rounds. The Plan denied your request. The 
Plan says the records do not show that the enrollee needs continued treatments that can only be given in a 
hospital setting. 
 
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 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 she is currently 
receiving 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided March 
11, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you would like this service covered. The Plan 
denied your request. The Plan says this service is not covered because it was performed as part of a medical eye 
exam.  
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 these services when performed as part of a routine exam. 
 
We looked at the file and the Plan's rules. In this case the eye refraction was billed with a medical eye exam. 
Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided March 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia provided on October 27, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that the provider was certified on this date of service and 
eligible to perform anesthesia services. You say that the claim should be reconsidered for payment. The Plan 
denied your request. The Plan says that anesthesia codes are reimbursed to anesthesia providers only. 
 
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 has not provided a valid rationale for why the rendering provider type 
is not appropriate for anesthesia services. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the anesthesia provided on October 27, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care telehealth services provided on January 15, 
2022. 
 
You asked the Plan to pay for the services provided. You say that services were rendered for treatment of an 
acute stroke. The Plan denied your request. The Plan says the modifier is inappropriate for the services. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code G0508 is telehealth consultation, critical care, initial, 
physicians typically spend 60 minutes communicating with the patient and providers via telehealth. 
 
We find that CPT code G0508 was billed with a GO modifier. This modifier is only for services provided 
under plans of care for occupational therapy services. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the critical care telehealth services provided on January 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nivolumab. 
 
You asked the Plan to pre-approve nivolumab. 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 must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 nivolumab. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided, 
guidelines of the National Comprehensive Cancer Network and the Medicare-approved major drug compendia 
there is no documentation that the nivolumab meets Medicare criteria for safe and effective for the enrollee. 
Metastatic basal cell carcinoma is not a medically-accepted indication for the requested use of nivolumab as 
defined by Medicare 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 nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nivolumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision of excessive skin and subcutaneous tissue of 
the arm (15836). 
 
You asked the Plan to pre-approve an excision of excessive skin and subcutaneous tissue of the arm. You say 
that the requested service is a medical necessity for you. The Plan denied your request. The Plan says rules for 
coverage have not been met because the requested service is cosmetic in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 excision of excessive skin and 
subcutaneous tissue of the arm. Our reviewer says that the requested service is not medically reasonable and 
necessary in this case. Our reviewer found that the clinical documentation supports that the requested 
brachioplasty surgery is cosmetic in nature rather than functional. 
 
 
 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 excision of excessive skin and subcutaneous tissue of the arm have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an excision of excessive skin and 
subcutaneous tissue of the arm (15836).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve various genetic testing including BRCA1, BRCA2, 
MLH1, MSH2, MSH6, PMS2, and molecular pathology procedure level 9 (next generation genetic 
sequencing). 
 
You asked the Plan to pre-approve various genetic testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are 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 various genetic testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of prostate cancer with evidence of a biochemical 
recurrence with a prostate specific antigen level of 1.1 ng/mL in January 2021. There is no documentation that 
the enrollee has a diagnosis/condition that meets criteria for the requested services. The provided records do not 
document at least one close blood relative with ovarian cancer, pancreatic cancer, or metastatic prostate cancer 
at any age or breast cancer (at 50 years of age or less); or at least 2 close blood relatives with breast cancer, or 
prostate cancer (any grade) at any age; or Ashkenazi Jewish ancestry or a personal history of metastatic prostate cancer which is biopsy proven. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
The Plan uses Local Coverage Determination (LCD), L36715 to support their denial. However, the LCD used 
is not valid for the enrollees home state of New York. This means this LCD is the incorrect jurisdiction and 
therefore, we are unable to use LCD L36715 to support our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of various genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve various genetic testing including BRCA1, BRCA2, MLH1, MSH2, MSH6, 
PMS2, and molecular pathology procedure level 9 (next generation genetic sequencing).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee arthroplasty of the right knee. 
 
You asked the Plan to pre-approve total knee arthroplasty of the right knee. You say that the right knee has 
already been done and that it is medically necessary to have the left knee done. The Plan denied your request. 
The Plan says the request is not medically necessary because the records submitted do not show that the 
enrollee has tried physical therapy to help her knee problems. 
 
The Plan follows Medicare rules. Medicare rules say that TKR is covered for certain medical indications.  
 
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 total knee arthroplasty of the right knee. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found detailed 
documentation is not evident regarding any right knee objective findings on the provided documentation. The 
objective examination focuses on the left knee. The request was for a total right knee arthroplasty. The 
computed tomography (CT) of the right knee reveals a severe tri-compartmental change. However, the noted 
criteria for coverage also states that the advanced joint disease must be demonstrated on radiographs or 
magnetic resonance imaging (MRI.) These diagnostic imaging studies were not provided. Less invasive, recent, 
reasonable and comprehensive combination of treatments has not been documented to have been tried and 
failed. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total knee arthroplasty of the right knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve total knee arthroplasty of the right knee.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment for swelling soft tissue to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve treatment for swelling soft tissue 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 
treatment for swelling soft tissue to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity. 
 
You asked the Plan to pre-approve an MRI of the lower extremity. 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 must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lower extremity. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found you are not 
wheelchair bound, but no details as to the reason. There is no history of trauma noted. Physical exam of the left 
hip was cursory. No findings noted. No plain film results in the records. Orthopedic referral is planned but not 
yet done. Medical necessity for an MRI of the left hip has not been established in the records provided. 
 
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 MRI of the lower extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower extremity.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided on October 14, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says that these services were previously billed by 
and paid to another provider. 
 
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. In this case, no evidence was provided by the Plan to indicate that these services 
had previously been billed and paid to another provider.  Therefore, we decided that the Plan has to pay for the 
medical services provided on October 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not have a diagnosis of syncope. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of an ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) for the 
enrollee.