Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299). 
 
You asked the Plan to pre-approve direct skilled nursing services of an RN. You say that you feel the enrollee 
should be approved for more visits because the enrollee has developed anxiety and depression which have been 
causing their health to take a downturn. You also say that the enrollee should begin to improve with home 
health visits. The Plan denied your request. The Plan says the current request for care does not require the skills 
of a licensed nurse. The Plan also says that the requested care is for convenience and does not meet criteria.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 direct skilled nursing services of an RN. 
Our reviewer says that direct skilled nursing services of an RN are not reasonable and necessary. Our physician 
reviewer found there is no documentation that additional skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The provided records do 
not document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate any further skilled nursing visits beyond what have already been approved. Our reviewer found that 
no medical notes from the enrollee's treating physician are provided documenting an order or need for 
additional skilled nursing services. Our physician reviewer also found that the records do not document the 
need for intravenous medications, new tube feeding, or ostomy care or daily complex wound 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 direct skilled nursing services of an RN have not been met. Therefore, we 
decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
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 provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic massage services provided on January 19, 
2022. 
 
You asked the Plan to pay for the therapeutic massage services. You say that you have chronic low back pain. 
You say that you have tried physical therapy and chiropractic care but still have pain. You say that you have 
been trying all of the options. You also say that you cannot walk due to the pain. The Plan denied your request. 
The Plan says therapeutic massage services are not covered as a supplemental benefit. 
 
Medicare generally does not cover supplemental services. However, the Plan offers a supplemental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the therapeutic massage 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the therapeutic massage services provided on January 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech production evaluation provided on February 1, 
2022, billed with two units of code 92522. 
 You asked the Plan to pay for the services as billed. You say that this should be paid. The Plan denied your 
request. The Plan says no payment can be made as two units of 92522 are not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 92522 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the speech 
production evaluation provided on February 1, 2022, billed with two units of code 92522.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the telephone evaluation, surgery, and 
imaging services provided from January 28, 2022, to March 14, 2022. 
 
You asked the Plan to waive the copayments for the telephone evaluation, surgery, and imaging services. You 
say that you were told that if you had authorization then this would be charged as an inhouse surgery, with a 
charge of $275. 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 $45 
copayment for each specialist visit and $90 copayment for vascular studies. Your contract with the Plan says 
that you must pay a $440 copayment per visit for outpatient procedures at a non-preferred facility. 
 
You have been asked to pay $575 in copayments for a telephone evaluation, surgery, and imaging services. The 
telephone evaluation with a specialist falls within the Physician/Practitioner Services, Including Doctors 
Office Visits benefit category. The surgery at a non-preferred facility falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The duplex scan of extracranial arteries falls with the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the 
telephone evaluation, surgery, and imaging services provided from January 28, 2022, to March 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ sacroiliac (SI) joint stabilization system. 
 
You asked the Plan to pre-approve LinQ SI joint stabilization system. You say that since all non-operative 
approaches have failed to alleviate the pain, this procedure is deemed to be medically necessary. The Plan 
denied your request. The Plan says this procedure is considered experimental/investigational. 
 
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 LinQ SI joint stabilization system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is experimental. More research is needed to show its safety 
and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LinQ SI joint stabilization system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the LinQ sacroiliac (SI) joint stabilization system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography services billed with codes 95885-
TC, 95908-TC and 95938-TC for date of service September 23, 2021. 
 
You asked the Plan to pay for codes 95885-TC, 95908-TC and 95938-TC. You say that these services were 
reported correctly. The Plan denied your request. The Plan says these services were not billed in accordance 
with Medicare regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that all items and non-physician 
services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under 
arrangements. This provision applies to all hospitals, regardless of whether they are subject to PPS. We looked at the file and Medicare rules. The record shows that CPT codes 95908, 95885, and 95938 were 
billed with the TC modifier. The technical component of these codes is included in the payment to the facility. 
This means that separate payment may not be made. Based on this information, we decided that Medicare rules 
for coverage of codes 95885, 95908 and 95938 have not been met. Therefore, we decided that the Plan does not 
have to pay for needle electromyography services billed with codes 95885-TC, 95908-TC and 95938-TC for 
date of service September 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 screening (0202U) provided on January 27, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the COVID-19 screening. The Plan denied your request. The Plan says this is a 
non-covered code. 
 
The Plan must follow Medicare rules. Medicare rules say CPT 0202U is not covered. 
 
We looked at the file and Medicare rules. Medicare does not provide coverage for the denied code. Based on 
this information, we decided that Medicare rules for coverage of the COVID-19 screening have not been met. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 screening (0202U) provided on 
January 27, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the request for a home mechanical ventilator set in average volume-assured 
pressure support mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. You do not have a neuromuscular disease, 
thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
Our physician reviewer found that your condition does not meet Medicare criteria for a home ventilator. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance image (MRI) of the cervical spine without 
contrast (72141). 
 
You asked the Plan to pre-approve an MRI of the spine. You say that approval has been supported by 
submission of clinical records. The Plan denied your request. The Plan says that the clinical information 
submitted does not demonstrate that a cervical spine MRI can be considered medically necessary. 
 
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 spine. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the enrollee reports neck pain. Onset had 
been following an expansion of a thoracic fusion. In such a setting there is the differential possibility that there 
would have been a change (or changes) post-surgery that led to this new finding/symptom. In such a cease, 
despite the negative neurological exam, it would otherwise be reasonable and necessary to further evaluate the 
enrollee's condition with advanced imaging given their surgical history. In as much, this request can be said to 
meet Medicare criteria for coverage. 
 
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 spine have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance image (MRI) of the cervical spine without contrast (72141).  
 
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 use of Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does 
not have an accepted indication for Tecentriq. 
 
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 Tecentriq. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Tecentriq. Our physician reviewer found 
PD-L1 expression on 1% or more of tumor cells is required for approval, but no testing is reported. The 
requested use of Tecentriq is not supported by one of the major drug compendia or by clinical research 
appearing 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Tecentriq.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy for breast cancer including an initial phase of 28 
fractions of Intensity Modulated Radiation Therapy (IMRT) with Image Guided Radiation Therapy (IGRT) and 
a Boost Phase of 5 fractions of Intensity Modulated Radiation Therapy (IMRT) with IGRT. 
 
You asked the Plan to pre-approve radiation therapy. You say that 3D Comparison charts attached showing that 
IMRT is better and safer for the enrollee because IMRT reduces left lung v20 from 23.8% to 8.4% and does not 
increase heart-mean dose. The Plan denied your request. The Plan says that the requested service is not 
reasonable and necessary under Medicare guidelines. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found for this enrollee, with 3D conformal radiation, the lung exposure is excessive, and IMRT with 
IGRT reduces the exposure to acceptable exposures. It is safe to say that IMRT is not experimental, but rather a 
useful tool available to radiation oncologists to potentially reduce toxicity and improve the lung, heart and skin 
dose distributions. In light of the dosimetric improvement with IMRT in this enrollee, as well as ASTROs 
most recent update of its Choosing Wisely list, IMRT would be furnished in accordance with accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have been met. Therefore, we decided that the Plan has to pre-
approve radiation therapy for breast cancer including an initial phase of 28 fractions of Intensity Modulated 
Radiation Therapy (IMRT) with Image Guided Radiation Therapy (IGRT) and a Boost Phase of 5 fractions of 
Intensity Modulated Radiation Therapy (IMRT) with IGRT.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 12, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on July 12, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing services provided on March 10, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test was used to aid in the management of 
the enrollee. The Plan denied your request. The Plan says that the claim was submitted after the filing limit. 
 
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 documentation in the case file does not show that more than one calendar year from the date of service had 
passed before a claim was filed. The Plan has not made reasonable and diligent efforts to gather and forward to 
us information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the lab testing services provided on March 10, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service December 
28, 2021. 
 You asked the Plan to pay for procedure code 74018. You say that  The Plan denied your request. The Plan 
says payment for code 74018 is bundled into payment for code 74340. 
 
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 74018 
is a column II code to column I code 74340. 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 procedure code 74018 billed for date of service December 28, 
2021.