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

 
We decided that the Plan does not have to pay for the biopsy (55700) and ultrasound (76872) provided on July 
26, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the biopsy (55700) and ultrasound (76872) 
provided on July 26, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee has been receiving these 
services for over a year. You say that this has provided significant improvement in the enrollee's pain, 
functionality, and quality of life. You also say that the enrollee has failed to respond to more conservative 
measures. The Plan denied your request. The Plan says this treatment is experimental and therefore is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/ investigational therapy. It is the subject of 
ongoing clinical trials. Therefore, the reviewer found that the requested genicular nerve block is 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance (64624).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the chest. 
 
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 that the requested CT scan 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 
request is medically necessary. Our physician reviewer found that the enrollee has a risk for cancer given 
history of smoking and an abnormal CT scan. Given their predisposition for malignancy risk, a CT chest is not 
absolutely unnecessary. Follow up imaging within six months to one year for nodules less than 6-millimeter. 
The Fleischner guidelines, it can be up to one year. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a CT scan of the chest.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on July 17, 2023. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you want to appeal the amount 
being charged. 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 $300 
copayment for outpatient surgery including services provided at hospitaloutpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $300 copayment for the colonoscopy. This item/service falls within the 
outpatient surgery including services provided at hospitaloutpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy provided on 
July 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Midodrine HCL. 
 
You asked the Plan to pre-approve Midodrine HCL. You say that the enrollee needs for treatment of orthostatic 
hypotension. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 Midodrine HCL. 
 
Benefits for Midodrine HCL may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tie down kit. 
 
You asked the Plan to pre-approve a tie down kit. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
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 pre-approve a tie down kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve limited oral evaluation - problem focused (D0140), 
pulpal debridement, primary and permanent teeth (D3221), surgical procedure (D3910), unspecified 
endodontic procedure (D3999), and drugs or medicaments dispensed in the office (D9630. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the limited oral evaluation has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on date of service September 21, 2023, and 
October 30, 2023. Pulpal debridement, primary and permanent teeth is covered for ages 0-20. A surgical 
procedure, unspecified endodontic procedure, and drugs or medicaments dispensed in the office are not 
covered services Therefore, we decided that the Plan does not have to pre-approve limited oral evaluation - 
problem focused (D0140), pulpal debridement, primary and permanent teeth (D3221), surgical procedure 
(D3910), unspecified endodontic procedure (D3999), and drugs or medicaments dispensed in the office 
(D9630).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the immunohistochemistry testing provided on July 17, 2023, billed 
with 3 units of code 88341. 
 
You asked the Plan to pay for the 3 units of code 88341. You say that this was billed for medically necessary 
testing.  The Plan denied your request. The Plan says that 11 units were paid on a separate claim. The 
additional 3 units exceed the Medically Unlikely Edits (MUE) amount of 13 units. There is no evidence to 
show this number was medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that The Plan has not provided sufficient information to support the 
denial of payment in this case. While it is noted that 11 units were billed and paid on another claim, no copy of 
this claim or remittance advice was submitted as evidence to support this. As it stands, only 3 units were billed 
which does not exceed the MUE.  Therefore, we decided that the Plan has to pay for the immunohistochemistry 
testing provided on July 17, 2023, billed with 3 units of code 88341.  
 
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 pay for practitioner services provided on May 25, 2023, billed with 
procedure code 99204-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says 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 99204-25 is office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter. 
 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that although the documentation included 
a medically appropriate history and examination, the documentation did not support a moderate level of 
medical decision-making or included the duration of the encounter lasting 45-59 minutes as required for the 
code 99204.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 25, 2023, billed with procedure code 
99204-25.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have 
a medical need for multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria are met. 
 
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 Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided documentation indicates that the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. The reviewer also found that the record does not support the 
enrollee requires seat elevation for transfers or activities of daily living (ADLs). Therefore, the reviewer found 
that the requested Group 3 power wheelchair with multiple power options is 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, legrests, seat elevator) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart System. 
 
You asked the Plan to pre-approve an Optimizer Smart System. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 an Optimizer Smart System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, cardiac contractility 
modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the CCM 
system would not be considered medically necessary in this 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 an Optimizer Smart System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart System.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee has completed treatment with 
carboplatin and Alimta. You also say that a recent positron emission tomography (PET) with computed 
tomography (CT) scan shows that the disease is progressing. The Plan denied your request. The Plan says the 
requested use of this drug is not indicated for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested use of Keytruda is not medically necessary. Our physician reviewer found the provided documentation does not support that the requested use of this drug is approved by the Food and Drug 
Administration (FDA) for the enrollee's condition. Specifically, the records do not include a PDL1 score. The 
reviewer also found that the requested use is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested use 
of Keytruda is 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show a medical need to control the 
power options through a joystick. 
 
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 upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation supports that the enrollee does have use of the upper 
extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. Therefore, the reviewer found that the requested upgraded electronics 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
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 the enrollee would benefit from a critical 
illness recovery hospital to allow for more time to maximize recovery and allow for a stable discharge. The 
Plan denied your request. The Plan says the enrollee's care needs include tube feedings, and the enrollee may 
need a long-term enteral feeding tube placed, but after the Percutaneous Endoscopic Gastrostomy (PEG) tube 
placement when the enrollee is ready to leave the hospital, the plan says the enrollee can receive this care in 
another setting like a Skilled Nursing Facility or Long-Term Care facility. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is not 
medically necessary. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart catheterization and ventriculography. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be approved. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity for performance of cardiac catheterization. The 
enrollee had a normal stress test two years ago. A recent stress test has not been performed. The medical 
records provided do not support the rationale for this invasive imaging study. The guidelines do not support a 
need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and necessary in this enrollee's 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve heart catheterization and ventriculography.