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

 
We decided that the Plan does not have to pre-approve intensity modulated radiation treatment (IMRT) 
(77386). 
 
You asked the Plan to pre-approve IMRT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no high-quality evidence that this type of radiation therapy is needed or effective 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it shows a slight violation for the spinal cord and spinal cord_PRV05 with the three-
dimensional conformal radiation therapy (3DCRT) plan. This can be resolved by re-planning and re-
optimization. The IMRT/volumetric modulated arc therapy (VMAT) plan has some dosimetry advantages. 
However, given very extensive bilateral (B/L) lymphadenopathy and large primary tumor, dose/fractionation 
schedule, and radiation treatment intent (palliative), the 3DCRT plan is equally safe and effective in this case. 
IMRT/VMAT is unlikely to provide superior outcomes (considering palliative treatment goals) and/or 
clinically significant lower acute and long-term radiation-induced toxicities, particularly considering the 
expected life expectancy of this enrollee with metastasis (M1) disease initially diagnosed in March 2022. 
Therefore, IMRT/VMAT is not medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation treatment (IMRT) (77386).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paring or cutting of benign hyperkeratotic lesion  
(e.g., corn or callus); single lesion provided on April 14, 2023. 
 
You asked the Plan to pay for paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single 
lesion. You say that you went to your first visit with your PCP on April 14, 2023 as a new patient, and he went 
over your medical history and you had expressed to him that the callus on your foot is very painful and the 
doctor offered to remove the callus and you said yes and you were unaware that this service wasn't covered. 
The Plan denied your request. The Plan says there is no clinical documentation indicating that you have a 
systemic disease, such as metabolic, neurologic, or peripheral vascular disease of sufficient severity that 
performance of the services by a nonprofessional would put you at risk.  
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
 Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of paring 
or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion have not been met. Therefore, we 
decided that the Plan does not have to pay for paring or cutting of benign hyperkeratotic lesion  
(e.g., corn or callus); single lesion provided on April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on August 09, 
2022. 
 
You asked the Plan to pay for an office visit and related services. You say that the services 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 an office visit and 
related services provided on August 09, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and services provided on 
November 10, 2021. 
 
You asked the Plan to pay for the emergency department visit and services. You say that the claim was 
submitted well within the payer limits. The Plan denied your request. The Plan says this claim was processed 
correctly due to the claim not being filed until March 29, 2023, without good cause. The Plan also says that this 
means more than one calendar year from the date of service had passed before the claim was filed. 
 
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 emergency department visit and services was not filed until March 29, 
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 emergency department visit and services 
provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 08, 2022. 
 
You asked the Plan to pay for an office visit. You say that you were unaware that this service needed 
authorization. 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 an office visit provided 
on July 08, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you believe that this should be covered in 
order to stay proactive in your health. The Plan denied your request. The Plan says the service is a covered 
benefit, but you have met the Plan limits which have been set in the subscriber agreement. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, you have asked to 
be transported more than 50 miles one way under your transportation benefit. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99232 & 99233 provided on December 10, 
2022 to December 19, 2022. 
 
You asked the Plan to pay for procedure codes 99232 & 99233. You say that this service was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 definitions of codes 99232, & 99233 are Subsequent hospital care, per day, 
for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An 
expanded problem focused interval history; An expanded problem focused examination; Medical decision 
making of moderate complexity and Subsequent hospital care, per day, for the evaluation and management of a 
patient, which requires at least 2 of these 3 key components:  A detailed interval history ; A detailed examination; and Medical decision making of high complexity. 
 
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 procedure codes 99232 & 99233. Our reviewer says that the 
records do not support the billed services. Our reviewer found while the records show appropriate histories for 
the billed codes, the records do not support medical decision making of moderate or 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 procedure codes 99232 & 99233 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 99232 & 99233 provided on December 10, 2022 to 
December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) with a naturopathic doctor.  
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says Medicare does not cover office visits with 
naturopathic doctors, 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pre-approve an office visit (99214) with a naturopathic doctor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request cannot be approved, as there is not enough evidence showing that this 
device would improve outcomes. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 
17, 2022, to October 16, 2022. 
 You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the enrollee no longer required skilled services.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee no longer qualified for SNF coverage. The enrollee did not have 
documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled 
services were not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs were custodial and could, as a practical matter, be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from September 17, 2022, to October 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative identification (eg, mapping) of sentinel 
lymph node(s) includes injection of non-radioactive dye (38900) and the mastectomy (19302) provided on 
December 28, 2022. 
 
You asked the Plan to pay for the services. You say that the refund request was incorrect. The Plan denied your 
request. The Plan says the documentation does not support the billed code.  
 
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 19302 is mastectomy, partial (e.g., lumpectomy, 
tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy. 
 
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 found the documentation 
submitted was reviewed and does not meet criteria. The procedure report does not include sufficient 
documentation to confirm a partial mastectomy with axillary lymphardenectomy. In this case, operative report 
describes lumpectomy with sentinel node biopsy and there is a more appropriate code to report for service 
provided. Code 38900 is denied as the main procedure code (19302) is not supported. 
 
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 the intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of 
non-radioactive dye (38900) and the mastectomy (19302) provided on December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body, endosteal 
(D6010), a bone graft at time of implant placement (D6104), a semi-precision abutment, placement (D6191), a 
semi-precision attachment (D6192) and a partial, maxillary overdenture (D5864). 
 
You asked the Plan to pre-approve a surgical placement of implant body, endosteal (D6010), a bone graft at 
time of implant placement (D6104), a semi-precision abutment, placement (D6191), a semi-precision 
attachment (D6192) and a partial, maxillary overdenture (D5864). You say that the reason you are placing an 
implant is to improve stability and retention of the upper partial overdenture. The Plan denied your request. The Plan says surgical placement of implant bodies, endosteal (D6010), bone grafts at time of implant placement 
(D6104), and semi-precision abutments, placement (D6191) do not meet criteria. The Plan also says that a 
semi-precision attachment (D6192) and a partial, maxillary overdenture (D5864) are not a covered benefit.  
 
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. The Plan covers surgical 
placement of implant body, endosteal (D6010), bone graft at time of implant placement (D6104), a semi-
precision abutment, placement (D6191) and when the services are medically necessary and reasonable. Semi-
precision attachments (D6192) and a partial, maxillary overdenture (D5864) are not a covered benefit. 
 
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 surgical placement of implant body, 
endosteal (D6010), bone graft at time of implant placement (D6104), a semi-precision abutment, placement 
(D6191) and. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation provided does not meet the criteria for coverage for an implant, bone graft and implant 
abutment for area number 12 due to multiple missing teeth in the arch. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of surgical placement of implant body, endosteal (D6010), bone graft at time of 
implant placement (D6104), a semi-precision abutment, placement (D6191) and have not been met. Though the 
Plan offers a dental benefit in excess of Medicare coverage, a semi-precision attachment (D6192) and a partial, 
maxillary overdenture (D5864) are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve a surgical placement of implant body, endosteal (D6010), a bone graft at 
time of implant placement (D6104), a semi-precision abutment, placement (D6191), a semi-precision 
attachment (D6192) and a partial, maxillary overdenture (D5864).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ultomiris. 
 
You asked the Plan to pre-approve Ultomiris. You say that the requested Ultomiris is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Vyvgart first.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ultomiris. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Vyvgart 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ultomiris have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ultomiris.
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 you are requesting an expedited appeal 
of the LTACH denial. The Plan denied your request. The Plan says criteria for admission to the LTACH have 
not been met.  
 
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 the enrollee appears to be gradually improving with current treatment and 
requires short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and completion of treatment at the current facility is 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intravitreal injection of a pharmacologic agent (separate 
procedure) and injection, aflibercept, 1 mg provided on March 16, 2023. 
 
You asked the Plan to pay for the intravitreal injection of a pharmacologic agent (separate procedure) and 
injection, aflibercept, 1 mg. The Plan denied your request. The Plan says the provider not submitting detailed 
procedure notes that are needed in order to determine the clinical utility of the services performed. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the intravitreal injection of a 
pharmacologic agent (separate procedure) and injection, aflibercept, 1 mg have been met. Therefore, we 
decided that the Plan does not have to pay for an intravitreal injection of a pharmacologic agent (separate 
procedure) and injection, aflibercept, 1 mg provided on March 16, 2023.