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

 
We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you were referred to the requested provider by 
your cardiologist, to treat a new condition. This new condition is very risky and if not treated as soon as 
possible, it can complicate your health. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. There are available providers in the network that can render the 
service requested. 
 
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 
an office visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) care. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollees physician has said that the enrollee is 
an excellent candidate for IRF services. The Plan denied your request. The Plan says that the denial of IRF care 
is correct. 
 
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 
enrollee does not meet criteria for IRF care. Our physician reviewer found that the complexity of the enrollees 
nursing, rehabilitation, and medical needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. While the enrollee may benefit from physical and/or 
occupational therapy, the enrollees needs can be met in a lower intensity setting such as a skilled nursing 
facility. 
 
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 inpatient rehabilitation facility (IRF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of 
service December 20, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761 and 99072. You say that these services are 
supported in the medical records. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. In addition, codes 94761 and 99072 are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The rules also say that for molecular 
diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine 
whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is 
assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87631 
have not been met. 
 
In addition, we find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. We have also confirmed that procedure code 94761 
has a status indicator of T on the Physician Fee Schedule and was billed with other payable services under the 
physician fee schedule for the same date by the same provider. This means that procedure code 94761 is not 
separately payable in this case. Based on this information, we decided that Medicare rules for coverage of 
codes 99072 and 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87631, 94761 and 99072 billed for date of service December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the tray (E0950), lateral trunk or hip support (E0956), shoulder 
harness/straps or chest strap (E0960), and retractable or removable mounting hardware for joystick (E1028) 
provided on September 22, 2022. 
 
You asked the Plan to pay for the tray, lateral trunk or hip support, shoulder harness/straps or chest strap, and 
retractable or removable mounting hardware for joystick. You say that the enrollee's family paid for the 
modifications to the enrollee's wheelchair with the expectation of being reimbursed. The Plan denied your 
request. The Plan says that these accessories are not covered by Medicare. 
 
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 records do not support the Plan's denial in this case. This means that the 
Plan has not provided a valid reason for denying payment of the tray, lateral trunk or hip support, shoulder 
harness/straps or chest strap, and retractable or removable mounting hardware for joystick. It is the burden of 
the Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated. Therefore, 
we decided that the Plan has to pay for the tray (E0950), lateral trunk or hip support (E0956), shoulder 
harness/straps or chest strap (E0960), and retractable or removable mounting hardware for joystick (E1028) 
provided on September 22, 2022.  
 
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 positron emission tomography and computed 
tomography (PETCT) scan. 
 
You asked the Plan to pre-approve the PETCT scan. You say that the services are medically necessary to rule 
out prostate cancer due to the enrollee's elevated prostate-specific antigen levels. The Plan denied your request. 
The Plan says PETCT scans are not covered for the initial diagnosis and staging of prostate carcinoma. 
 
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 the PETCT scan. Our reviewer says that 
the PETCT scan is not medically necessary. Our physician reviewer found the records do not show that the 
enrollee has had a biopsy confirming prostate cancer. The most recent American urological association (AUA) 
guidelines state that enrollees with prostate cancer at high risk for metastatic disease with negative 
conventional imaging, may benefit from a positron emission tomography and computed tomography (PETCT) 
to evaluate for metastases. 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 PETCT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography and computed tomography (PETCT) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted suspension system (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. You say that the enrollee's current socket cannot provide the 
support needed to carry out their daily tasks. You also say that you are certain the provided information will 
meet the necessary criteria to overturn the denial and provide the enrollee with the socket replacement and the 
advance K3 foot. The Plan denied your request. The Plan says this request for this residual limb volume 
management system exceeds the enrollee's need and does not meet the Medicare criteria of reasonable and 
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 a VASS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the VASS does not significantly improve function when compared with usual prosthesis socket. 
Our reviewer also found that a VASS is not medically necessary as it is not of additional benefit. 
 
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 VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum assisted suspension system (VASS) (L5781).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673). 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says these devices are not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression devices (E0675, E0673).
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 you are requesting an expedited reconsideration for 
the denial of an IRF admission. You say you were independent and active before coming to the hospital, and 
you want to return to being independent. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to an IRF.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. You say that the enrollee continues to have severe 
nausea secondary to a medication side effect, and is not experiencing any relief with metoclopramide. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablets.  
 
Benefits for Ondansetron tablets 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for a sacroiliac joint; provision of 
anesthetic, steroid and/or other therapeutic agent, with or without arthrography (G0260). 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that you have difficulty doing the 
prescribed exercises at home because it makes your back and left sacroiliac joint very painful. The Plan denied 
your request. The Plan says you do not meet medical necessity guidelines. There has been at least three months 
of pain. 
 
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 sacroiliac joint injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found that you have chronic low back and sacroiliitis. You are taking Aleve for 
pain. You have been trying physical therapy, but you find it painful. You first noted this pain on April 6, 2023. 
The LCD requires that you try conservative therapy for 3 months before starting with SI joint injections. This 
time period has not lapsed.  Therefore, the request is deemed not medically reasonable and necessary at this 
point in 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 sacroiliac joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an injection procedure for a sacroiliac joint; provision of anesthetic, steroid and/or 
other therapeutic agent, with or without arthrography (G0260).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sertraline Hydrochloride (J8499). 
 
You asked the Plan to pre-approve Sertraline Hydrochloride. You say that the enrollee has tried Seroquel, 
Donepezil. You also say that the enrollee is having a positive response with the Sertraline Hydrochloride. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sertraline Hydrochloride 
(J8499).  
 
Benefits for Sertraline Hydrochloride 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on January 06, 2023. 
 
You asked the Plan to pay for the office visit (99213). You say that the service should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99213) 
provided on January 06, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services (99283) provided on June 
6, 2022. 
 
You asked the Plan to pay for the ER services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program.  Medicare covers services in an emergency department only if the 
emergency clinic is affiliated with a hospital.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services 
(99283) provided on June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pressure-reducing support surface. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a pressure-reducing support surface is covered 
when specific criteria are met. 
 
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 criteria for coverage are not met. Our physician reviewer found the records show that you have limited 
mobility due to your medical condition. The records do not support that you have multiple stage two pressure 
ulcers on the trunk or pelvis that have failed to improve in the previous month with conservative treatment. The 
records do not show that you have a skin graft or skin flap. The criteria for coverage are not met and the 
pressure-reducing support surface is not reasonable or medically necessary. 
 
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 a pressure-reducing support surface.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on August 18, 2022, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the x-ray provided OON . You say that the records provided support that the 
services in dispute were needed.  The Plan denied your request. The Plan says no medical necessity for an 
OON provider, such as an urgent or emergent situation, has been documented.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an x-ray provided on August 18, 2022, by an out-
of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visits and pay 
for the self-administered drug. 
 
You asked the Plan to waive the copayment for the ER visits and pay for the self-administered drug. You say 
that the services should be covered. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $110 
copayment for each visit for emergency care. Medicare Part B generally does not pay for drugs that are usually 
self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form 
and those used for self-injection. 
 
You have been asked to pay a $110 copayment for each visit for the ER visits and pay for the self-administered 
drug. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the emergency room (ER) visits and pay for the 
self-administered drug.