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) scan to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a PET scan to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 
a positron emission tomography (PET) scan to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right endovenous ablation. 
 
You asked the Plan to pre-approve right endovenous ablation. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. 
 
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 right endovenous ablation. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not meet coverage criteria and does not support the medical necessity of the treatment in question. 
Coverage criteria require that the symptoms in question be attributable to the veins planned for treatment. It is 
not possible to attribute the enrollees leg symptoms to the varicose veins without an assessment of lower 
extremity arterial perfusion. Additionally, it is not clear from the medical record that the enrollee is having 
lifestyle limiting symptoms despite the use of compression stockings. Furthermore, the medical 
necessity/appropriateness of venous treatments cannot be supported without an assessment of arterial perfusion 
to the lower extremities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right endovenous ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve right endovenous ablation.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that the enrollee has tried 
and failed Infed (iron dextran- Allergan has INFeD 50 mg/mL 2 mL vials available) and Venofer (iron 
sucrose). The documentation does not support that Infed (iron dextran- Allergan has INFeD 50 mg/mL 2 mL 
vials available) and Venofer (iron sucrose) would likely be less effective and/or likely have adverse effects for 
the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical documentation supports multifactorial low back pain supported 
by the magnetic resonance imaging of the lumbar spine and symptoms of radiculopathy. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has radiculopathy which is a contraindication to Intracept. There is no 
magnetic resonance imaging showing only modic changes without facet degenerative joint disease or foraminal 
stenosis.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied CGM and that the services requested are medically necessary. The Plan 
denied your request. The Plan says that the services requested are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a continuous glucose monitor (CGM). 
Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee is having 
severe low documented bgs. The CGM will help prevent the enrollee's bg from getting so low that they are 
symptomatic or loses consciousness. They have a history of diabetes mellitus in the past and is on medicine 
that is used for diabetes mellitus and also to prevent post prandial hypoglycemia.  
 
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 continuous glucose monitor (CGM) have been met. Therefore, we decided 
that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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 proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the enrollee meets the requirements. The Plan denied 
your request. The Plan says that PBRT is not the standard of care for prostate cancer and should only be used 
as the primary treatment for prostate cancer within the of a prospective clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that proton beam radiation therapy may be covered under 
certain circumstances. 
 
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 PBRT. Our reviewer says that proton 
beam radiation therapy is not medically reasonable and necessary in this case. Our physician reviewer found 
that there is insufficient prospective, long-term clinical data available to determine whether or not proton beam 
radiation therapy for prostate cancer is superior, inferior, or equivalent to external beam radiation therapy, 
intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. Recent 
data shows no significant differences in late (years one, two, and three) patient-reported toxicity outcomes 
between proton beam therapy and IMRT. The most recent guidelines state that PBT offers no clinical 
advantage over other forms of definitive treatment. According to guidelines, proton beam therapy may be 
offered to individuals enrolled in an Institutional review board- approved prospective clinical trial or multi-
institutional registry that adheres to Medicare requirements for Coverage with Evidence Development. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that this scooter is 
medically necessary for you. The Plan denied your request. The Plan says your request is not medically 
necessary 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the record indicates the enrollee is able to manage self-care in the home with a 
manual wheelchair.  
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle, patient weight 
capacity up to and including 300 pounds (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627) and miscellaneous 
durable medical equipment (E1399). 
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says  the criteria have not been met and the documentation does not support medical 
necessity. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 items. Our physician reviewer 
found you do not have severe arthritis or inability to rise from a chair. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a seat lift mechanism (E0627) and miscellaneous durable medical equipment (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET/CT scan. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that a PET/CT is medically necessary to look for 
the spread of prostate cancer and to determine the treatment for prostate cancer. The Plan denied your request. 
The Plan says the requested PET/CT is not medically necessary. A study similar to the one requested has 
already been approved. 
 
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 a PET/CT scan. Our reviewer says that 
a PET/CT scan is not considered medically necessary in this case. Our physician reviewer found that the 
medical records do not show that the enrollee is at high risk for metastatic prostate cancer with negative conventional imaging. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET/CT scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (procedure code L1812) provided 
on September 1, 2022. 
 
You asked the Plan to pay for the services. You say that this is needed to reduce pain by restricting mobility 
and facilitate healing following injury. 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 L1812 is "Knee orthosis, elastic with joints, 
prefabricated, off-the-shelf." 
 
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 medical records include a 
signed physician order for L1633; however, L1812 was what was delivered. The order does not support the 
billed code. 
 
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 durable medical equipment (procedure code L1812) provided on September 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on April 5, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 code 99285. Our reviewer says that the medical records do not support the billing of code 99285. Our reviewer found the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of a high level. 
 
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 code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on April 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 61312 rendered on May 14, 2023. 
 
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 a 10 or 90-day post operative procedure was not reported during the applicable post-operative 
period. 
 
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 61312 is "Craniectomy or craniotomy for evacuation of 
hematoma, supratentorial; extradural or subdural." 
 
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 provider reported the procedure code with appended modifier -78, for unplanned return to the operating/procedure room by the same 
physician or other qualified health care professional following initial procedure for a related procedure during 
the post-operative period. However, an initial procedure was not found in the medical record to verify the 
modifier used. 
 
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 procedure code 61312 rendered on May 14, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visits provided on June 22, 2023, to July 
13, 2023. 
 
You asked the Plan to pay for the mental health visits. You say that you are requesting reconsideration of the 
denied claim. 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 mental health visits 
provided on June 22, 2023, to July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 rendered on January 18, 2023. 
 
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 Current Procedural Terminology (CPT) code 93306 (1 unit) remains not supported. 
 
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 93306 is "Echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography." 
 
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 a review of the medical records 
does not reveal sufficient documentation to support the use of this code. 
 
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 procedure code 93306 rendered on January 18, 2023.
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 medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the 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 complexity of your nursing, medical and rehabilitation can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. While you may require treatment by multiple therapies, including physical therapy and 
occupational therapy, this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF, but the services required can 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 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.