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

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered from 
July 19, 2022, to July 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided documentation did 
not include any clinical notes that would verify a comprehensive history, physical exam, or medical decision-
making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered from July 19, 2022, to July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection.  
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria.  
 
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 epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that in this case, the epidural steroid injection performed on December 8, 2021, 
provided 50% pain relief but the duration of pain relief was not provided. The review has determined that the 
requested epidural steroid injection does not meet the Medicare LCD coverage 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 an epidural steroid injection.  have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional power wheelchair accessories (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that management of power features using a single joystick controller, rather than 
through their own switches, is not reasonable and necessary in this enrollee's scenario. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 accessories. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee cannot perform pressure relief independently due to weakness and requires a power 
wheelchair with power tilt and recline for adequate pressure relief and positioning. The enrollee also requires 
power elevating leg rests for positioning of her lower extremities and spasticity. The complexity of the 
enrollee's seating and positioning needs necessitates a more complex group 3 power wheelchair base. The 
expandable controller with harness and electronic connection are necessary to operate the group 3 power 
wheelchair base and the three power options, including, tilt, recline and elevating leg rests, via a joystick. 
 
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 accessories have been met. Therefore, we decided that the Plan has to pre-
approve additional power wheelchair accessories (E2311, E2313, E2377).  
 
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 Stereotactic Body Radiation Therapy (SBRT) (77373, 
77470). 
 
You asked the Plan to pre-approve SBRT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no good evidence the SBRT treatment is safe or effective or best for the 
enrollee's cancer. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found with stereotactic radiation, technologies to improve targeting accuracy are used to allow for 
higher dose delivery in 5 or fewer fractions. The combination of proximity of critical structures to the target, as 
well as the very high dose delivered per treatment fraction necessitates many fields to deliver a more conformal 
dose. Generally, for lung tumors, the goal with SBRT is to maximize dose delivery to the target, and minimize 
dose delivery to the normal lung, heart (for left sided tumors), liver (for right sided tumors), chest wall, trachea, 
esophagus and spinal cord without compromising lung tumor dose. This enrollee has metastatic disease, and 
the intent is palliative (per the consult note which inexplicably does not describe what the plan for treatment in 
this enrollee is). For such a situation of palliation in the setting of widespread metastases, SBRT is not an 
accepted standard of care, and the case file does not provide justification for SBRT. The LCD criteria are not 
met. The decision is therefore unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRT) (77373, 77470).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a continuation of care with an OON provider. You say that you have seen 
the requested OON provider since 2020, when you were diagnosed. You say that the cancer you had has a high 
risk of recurrence. You say that you also have trouble with your vision and the requested OON provider is 
closer to your home.  The Plan denied your request. The Plan says the clinical notes do not show a compelling 
reason why the services could not be provided in-network.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met.  Our physician 
reviewer found you are not currently receiving any active treatment and/or medical management of your 
condition that makes it medically necessary to continue care with the OON provider as requested. You are 
three years out from completion of therapy on surveillance. There is nothing unique about your condition that 
would make it medically necessary to continue care with the OON provider. The Plan has shown that they have 
in-network specialists who have the qualifications and expertise necessary to meet the current medical 
Standards of Care required for treatment of your condition. Your medical management and/or follow-up care 
you are seen for every 6 months can be safely transitioned to an in-network specialist. 
 
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 continuation of care with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart with quantitative evaluation of 
coronary calcium. 
 
You asked the Plan to pre-approve the CT scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found that the requested test is currently 
used for deciding about stating statins in individuals with an intermediate 10-year risk of cardiovascular events. 
There are no indications for the requested procedure. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT scan of the heart with quantitative evaluation of coronary calcium.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on December 30, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on December 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2017 billed for date of service January 3, 
2023 to January 6, 2023. 
 
You asked the Plan to pay for procedure code H2017. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2017 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code H2017 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2017 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2017 billed for date of service January 3, 2023 to January 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thyroid imaging (78013). 
 
You asked the Plan to pre-approve thyroid imaging. You say that you disagree with the denial. The Plan denied 
your request. The Plan says a thyroid medicine scan can be obtained if thyroid function test blood work is 
abnormal, and an ultrasound of the thyroid gland has been done. The enrollee does not meet criteria for this 
test. 
 
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 thyroid imaging. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has an elevated parathyroid level to 149 and a Ca++ 10.8. 
There is no indication for a thyroid scan. Per Medscape Internal Medicine, the thyroid uptake and scan are a 
radiologic diagnostic tool used to determine the thyroid function and pathologies. This diagnostic procedure 
works on the principle of the unstable nuclide of the atom, which tries to attain stability by releasing an alpha, 
beta, and gamma rays. Clinicians use these rays for diagnostic and treatment purposes. The test uses a 
radioactive tracer, which is a protein or a molecule attached to radioactive material. The radioactive tracer is 
administered into the enrollee, and a probe measures the amount of iodine uptake by the thyroid gland. The 
thyroid scan checks for the even spread of the tracer in the gland. More than 20 radioactive tracers exist, of 
which two isotopes of iodine I-123 and I-131 and 99m-technetium pertechnetate, are the usual agents used in 
this test. I-131 has a longer half-life than I-123, so I-123 is used more frequently than I-131 due to less 
radiation exposure to the body. 99m-Technetium pertechnetate is an analog of iodine, so it gets transported to 
the thyroid gland similarly to iodine. 111In-pentoxide, thallium-201 (201T1), 99mTc-sestamibi, 99mTc-
tetrofosmin are some of the less commonly used radioactive tracers in this test. This test is different than 
radioactive iodine therapy, which treats thyroid cancers. The review has determined that the items/services at 
issue in this case are not medically reasonable or 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 thyroid imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thyroid imaging (78013).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser treatment of the skin (0479T and 0480T). 
 
You asked the Plan to pre-approve the services. You say that this is the most appropriate method for treating a 
burn scar.  The Plan denied your request. The Plan says this procedure is unproven.  
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has tight, hypervascular, hypertrophic, painful scarring 
following a burn injury. There is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laser treatment of the skin (0479T and 0480T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of vacuum pumps for residual limb volume management and moisture 
evacuation systems among amputees is unproven and not medically necessary due to insufficient evidence of 
safety and/or efficacy. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the use of vacuum pumps for residual limb volume management and moisture evacuation systems 
among lower extremity amputees is unproven and not medically necessary due to insufficient evidence of 
safety and/or efficacy. The physician documentation does not reveal extenuating factors that require an elevated vacuum system. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vacuum socket system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve US-IGRT services. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 US-IGRT services. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that using ultrasound on a daily basis is not necessary. To bill for daily simple simulations 
and/or IGRT for a technology for which need has not been established by published data or supported by 
consensus guidelines (many of which recommend against treatment with these devices in general) is not necessary. Daily IGRT would not 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 US-IGRT services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasound-guided radiation therapy (US-IGRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
December 13, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not 
used in clinical management, exceeds the needs of the enrollee.  
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided documentation did not clearly show unexpected urine screening results to justify 
follow-up confirmation testing. Also, there was insufficient support made for testing 22 drug classes which is 
excessive as many of these drug classes were not clinically relevant to the enrollee's history. The enrollee did 
not meet the criteria for this testing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) rendered on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on January 9, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an eye exam. You say that this should be covered. The Plan denied your request. 
The Plan says this 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 an eye exam provided on January 9, 2023, by an 
out-of-network (OON) provider.