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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that the services are medically necessary. The 
Plan denied your request. The Plan says these types of scans are not covered for surveillance imaging. 
 
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 PET/CT scan. Our reviewer says 
that the PET/CT scan is not medically necessary. Our physician reviewer found the enrollee has had a negative 
biopsy and there is no diagnosis of malignancy, therefore a PET/CT scan is of no value or indicated. 
 
 
 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 4, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says the billed services are not supported. The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 4, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 30, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. 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 psychotherapy provided 
on January 30, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on March 7, 2023, to April 6, 
2023, by an OON provider.  
 
You asked the Plan to pay for the psychotherapy. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the psychotherapy provided on March 7, 2023, to 
April 6, 2023, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lidocaine 5% patch. 
 
You asked the Plan to pre-approve a Lidocaine patch. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 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 a Lidocaine 5% patch.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve the genicular nerve block. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there is no notation of intra-articular steroid or 
viscosupplement injections. The Plan also says this is experimental and therefore is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered experimental/investigation therapy at this time as it is the 
subject of ongoing clinical trials. Therefore, the reviewer found that the requested genicular nerve block is not 
medically reasonable and 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 the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 4, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the office visit. You say that you were provided with a temporary authorization 
number. The Plan denied your request. The Plan says their original decision to deny payment was correct. 
 
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 office visit provided on August 4, 2023, by an 
out-of-network (OON) provider.
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 IRF admission is necessary. The Plan denied 
your request. The Plan says you do not meet the criteria for IRF admission.  
 
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 the Plan is correct to deny IRF placement. There is no effort made in this record to 
suggest that the enrollee requires active and ongoing therapeutic intervention of multiple therapy 
disciplines.  Given the fact that the enrollee was discharged to home on the same day IRF was denied, it is not 
clear that anyone on the treating team actually supported the IRF request. If the enrollee stagnates / worsens at 
home, a new IRF request, with updated clinical notes justifying multi-disciplinary therapy and close medical 
management, would of course be considered. Therefore, the Plans denial of IRF placement, at this time and 
per the record submitted at this juncture, is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the periodic comprehensive preventive 
medicine evaluation provided by an in-network provider on April 5, 2023.  
 
You asked the Plan to waive the copayment for the preventive medicine evaluation. You say that you should 
not have a cost share. 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 after the first 12 
months of Part B coverage, you must pay a $30 copayment for in and out-of-network annual routine physical 
exams. 
 You have been asked to pay a $30 copayment for the preventive medicine evaluation. This item/service falls 
within the physician/practitioner services, including doctor's office visits 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 copayment for the periodic comprehensive preventive medicine evaluation provided 
by an in-network provider on April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home domiciliary visit provided on March 29, 2023. 
 
You asked the Plan to pay for a home domiciliary visit. You say that the services were medically necessary. 
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 a home domiciliary visit 
provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 01, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. 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 subsequent nursing 
facility care provided on May 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic eye exam (92014) and visual fiend exam 
(92083) provided on May 02, 2023. 
 
You asked the Plan to pay for the diagnostic eye exam (92014) and visual fiend exam (92083). You say that the 
service was medically necessary. 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 diagnostic eye exam 
(92014) and visual fiend exam (92083) provided on May 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 4, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says the billed services are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. 
 
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 records do not support that the refilling and 
maintenance of a portable pump, billed with code 96521, was provided. Based on this information, we decided 
that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to 
pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the photochemotherapy provided on June 
13, 2023. 
 
You asked the Plan to reduce the deductible for the photochemotherapy. You say that the service should be 
reprocessed at the in-network benefit level. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
 
 You have been asked to pay $131.80 towards your $1,000 deductible for the photochemotherapy. The item or 
service you asked the Plan to reduce the deductible for falls within the physician/practitioner services, 
including doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $1,000 deductible which applies to physician/practitioner services, including 
doctors office visits. This cost sharing is a contractual obligation that had not been met at the time the 
photochemotherapy was received on June 13, 2023. Therefore, we decided that the Plan does not have to 
reduce the deductible for the photochemotherapy provided on June 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 17, 2023, to 
July 16, 2023. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 17, 2023, to July 
16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) and pin retention (D2951) 
provided on June 5, 2023, and June 23, 2023. 
 
You asked the Plan to pay for periodontal maintenance and pin retention. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) and pin retention (D2951) provided on June 5, 2023, and June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6541 that 
were issued on December 16, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you believe the this has been coded 
incorrectly. The Plan denied your request. The Plan says the requested compression stocking is not a covered 
benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6541 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6541 that were issued on December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not covered. 
 
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 a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service March 8, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that the test is a Medicare covered service. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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 87640 is a column II code to column I code 87641. Code 87640 was 
billed with the -59 modifier. The medical records do not show that the service billed with the -59 modifier was 
a distinct procedural service. 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 87640 billed for date of service 
March 8, 2023.
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 an LTACH was recommended as the 
best setting by your physician to become independent of the ventilator. The Plan denied your request. The Plan 
says you do not meet the guidelines for care in an LTACH. 
 
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 you are receiving acute care services as needed in your current setting and can 
continue them until you can go to a lower level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on January 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until June 23, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the dental services provided on January 27, 2022.