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

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on January 20, 2023. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport, and ground 
mileage. You say that based on the enrollee's medical condition, no other mode of transport was appropriate. 
You also say that any lesser mode of transport was contraindicated and may have compromised the health and 
well-being of the enrollee.  The Plan denied your request. The Plan says this request is not medically necessary 
because the enrollee does not meet the criteria requirements outlined in Medicare rules for this service.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport, and ground mileage.  Our reviewer says that the ambulance transport services were not medically necessary. Our physician reviewer 
found the transportation via ambulance upon hospital discharge was not medically necessary. The enrollee did 
not require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair 
van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport, and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport, and ground mileage provided on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each office visit provided on March 23, 
2022, to November 22, 2022. 
 
You asked the Plan to waive the copayment for each office visit. You say that you thought this provider would 
be in-network. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for out-of-network primary care physician/practitioner services. 
 
You have been asked to pay a $25 copayment for each office visit. This item/service falls within the out-of-
network primary care physician/practitioner services 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. The records show this provider is out-of-network with the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for each office visit provided on 
March 23, 2022, to November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery; intermediate (77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy (PBRT). You say that this procedure is a 
covered Medicare benefit, and you are requesting reconsideration. The Plan denied your request. The Plan says 
the request is not medically necessary. A review of the literature indicates that PBRT is not the standard of care 
for prostate cancer and proton beam therapy for primary treatment of prostate cancer should only be performed 
within the context of a prospective clinical trial. 
 
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 proton beam radiation therapy (PBRT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no clear evidence that proton beam therapy for prostate cancer 
offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to 
establish a possible advantage of this expensive therapy. Notably, registry studies are not clinical trials or 
studies, and have a much less rigorous development process. A tumor registry does not address a specific 
scientific question but rather registers the enrollee's clinical and treatment information into a database for 
potential analysis in the future. Nevertheless, it is not specified if a clinical trial review was sought or whether 
this insurer allows for clinical trial exceptions. The decision is unfavorable as the reviewer does not believe the 
LCD criteria is met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy (PBRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve proton treatment delivery; intermediate (77523).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve Otezla. You say that Otezla represents viable and potentially effective 
treatment options for the enrollee's condition. 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 Otezla.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 27, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on February 27, 2023, by an out-of-
network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring provided on 
August 30, 2022.  
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring. You say that continuous 
intraoperative neurophysiology monitoring was medically necessary. The Plan denied your request. The Plan 
says that the requested continuous intraoperative neurophysiology monitoring is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for continuous intraoperative neurophysiology 
monitoring. Our reviewer says that the requested continuous intraoperative neurophysiology monitoring is 
considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee 
underwent a L4-5 laminectomy on August 30, 2022, with continuous intraoperative neurophysiology 
monitoring. The technology of IOM has markedly developed. It is certain that the significance and utilization 
of IOM during spinal surgery will increase because of medicolegal issues as well as its usefulness. Spinal 
surgeons should understand the concept of the monitoring techniques and interpret monitoring records 
adequately to use IOM for decision making during the surgery for safe surgery, favorable surgical outcome and 
the surgeon's medicolegal safety. The review has determined that the requested continuous intraoperative 
neurophysiology monitoring at issue in this case was 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 continuous intraoperative neurophysiology monitoring have been met. 
Therefore, we decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring 
provided on August 30, 2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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) 
chiropractor.  
 
You asked the Plan to pre-approve a continuation of care with an OON chiropractor. You say that you have 
seen this OON provider and would like to continue seeking treatment through him. You say that you feel 
comfortable with the OON provider you have already been seeing.  The Plan denied your request. The Plan 
says the necessary chiropractic care can 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 
chiropractor. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the records provided do not establish that you require emergent or urgent care or that you are 
receiving active treatment such that transferring your care and medical management to another provider would 
be medically inappropriate and/or contraindicated at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuation of care with an OON chiropractor 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) 
chiropractor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71100 billed for date of service November 1, 
2022.  
 
You asked the Plan to pay for procedure code 71100. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71100 is bundled into payment for code 
71101. 
 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 71100 
is a column II code to column I code 71101 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 71100 billed for date of service November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 20, 2023. 
 
You asked the Plan to pay for the home 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 the home visit provided 
on March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing provided on January 3, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that NGS is covered for the indications established in the 
applicable NCD. 
 
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 testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that In 
this case the enrollee is a 75 yo male with a diagnosis of cancer. There is no documentation indicating that the 
enrollee has: either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and not been 
previously tested with the same test using NGS for the same cancer genetic content, and decided to seek further 
cancer treatment (e.g., therapeutic chemotherapy). 
 
The review has determined that the requested Tempus xF testing is medically reasonable or necessary 
according to the above 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Tempus xF testing provided on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the grab bars. 
 
You asked the Plan to pre-approve grab bars. You say that you would like reconsideration because the 
requested grab bar is medically necessary. The Plan denied your request. The Plan says the requested grab bar 
is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve the grab bars.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foam sclerotherapy (36466 x2, 36465 x2). 
 
You asked the Plan to pre-approve foam sclerotherapy. 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 Medicare will consider invasive procedures (only 
with the techniques outlined in this local coverage determination (LCD) and under the conditions described) as 
reasonable and necessary when documentation in the medical record includes a history, physical examination, 
CEAP clinical classification, and a venous duplex scan documenting reflux (>500 msec). 
 
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 foam sclerotherapy. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no truncal reflux 
documented. Additionally, if the request is for sclerotherapy of tributary veins, the health plan does not provide 
for tributary vein sclerotherapy in the absence of associated truncal reflux requiring treatment. Therefore, 
criteria for tributary vein treatment not met. Additionally, it is documented that the varicose veins in question 
are asymptomatic. The criteria do not provide for treatment of asymptomatic varicose veins. The duplex also 
demonstrates abnormal tibial arterial waveforms. It is not possible to attribute leg symptoms or residual 
ulceration to the isolated varicose veins without demonstrating satisfactory arterial perfusion to the lower 
extremities. In summary, coverage criteria are not met, and the documentation does not support the medical 
necessity of the treatments in question.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of foam sclerotherapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve foam sclerotherapy (36466 x2, 36465 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service March 20, 
2023.   
You asked the Plan to pay for procedure code 64447. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 64447 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 64447 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64447 billed for date of service March 20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy.  
 
You asked the Plan to pre-approve physical therapy. You say that the requested out-of-network provider spends 
as much time with you as you need. The Plan denied your request. The Plan says you must receive your care 
from a network provider. 
 
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 
physical therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87631, 99072, 94761) provided on September 
26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. The rules also say that providers/suppliers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. We also find that procedure code 94761 has a status indicator 
of T on the Physician Fee Schedule. As there are other services payable under the physician fee schedule billed 
on the same date by the same provider, code 94761 is bundled into the physician services for which payment is 
made. Based on this information, we decided that Medicare rules for coverage of codes 99072 and 94761 have 
not been met. Therefore, we decided that the Plan does not have to pay for the services (87631, 99072, 94761) 
provided on September 26, 2022.