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

 
We decided that the Plan has to pre-approve proton beam treatment (PBT) (77370, 77387, 77470, 77523). 
 
You asked the Plan to pre-approve proton beam treatment. You say that the treatment is medically necessary. 
The Plan denied your request. The Plan says that there are not enough studies on PBT for breast cancer to show 
it is safe and effective. 
 
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 pre-approve proton beam treatment. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the use of proton therapy is an accepted radiation technology, that has proven 
efficacy and tolerability. Certain conditions such as base of skull chordomas and chondrosarcomas, and 
pediatric malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing 
high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. The reviewer does not 
think that proton therapy is investigational, but rather whether or not it is superior to non-proton-based intensity 
modulated radiation therapy (IMRT), for routine use, is an investigational question. For routine cases of post-
lumpectomy radiation, with the proper selection of beam angles, the lung or exposure is rarely problematic 
with breast cancer, especially using the techniques described above. As this enrollee had prior radiation to the 
same breast, this would not be a routine case, and the need for proton therapy would be plausible. The 
submitted plans are not composite plans, and therefore it is not unequivocal that proton therapy is needed to 
avoid exceeding the cumulative tolerance dose of nearby normal tissue. Despite these issues, in the setting of 
reirradiation, proton therapy would be considered to furnished in accordance with accepted standards of 
medical practice. The decision is therefore favorable. 
 
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 treatment have been met. Therefore, we decided that the Plan has 
to pre-approve proton beam treatment (PBT) (77370, 77387, 77470, 77523).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dental services provided by an out-of-
network provider on May 8, 2023 
 
You asked the Plan to waive the coinsurance for dental services. You say that you were told this provider was 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 50% coinsurance for dental services/out-of-network.  
 
The enrollee has been asked to pay a 50% coinsurance of the allowed amount for dental services. This 
item/service falls within the dental services/out-of-network benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the coinsurance for dental services provided by an out-of-network provider on May 8, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110 and 
D5120) provided on June 15, 2023. 
 
You asked the Plan to pay for D5110 and D5120. You say that your dentures broke and could not be fixed. You 
say that is why you needed these new dentures. The Plan denied your request. The Plan says the rendered 
dentures are not covered benefits. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
complete maxillary and mandibular denture (D5110 and D5120) provided on June 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 8, 2022, to 
November 11, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis of J15.6 (Pneumonia due to other Gram-negative bacteria) is supported by the medical record. The 
Plan denied your request. The Plan says the billed primary diagnosis of J15.6 (Pneumonia due to other Gram-
negative bacteria) is not supported by the medical record. Instead, J18.9 (Pneumonia, unspecified organism) is 
sequenced as the new primary diagnosis, and a lower DRG is paid. There is no clinical evidence within the 
health record to clinically validate the diagnosis of J15.6. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the primary diagnosis of J15.6 (Pneumonia due to 
other Gram-negative bacteria). 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the primary diagnosis of J15.6 
(Pneumonia due to other Gram-negative bacteria) is not supported by the medical record. Our physician 
reviewer found the enrollee is a 90-year-old woman who presented with hypotension. She was diagnosed with 
pneumonia and treated with IV hydration and antibiotics. In this case, the medical documentation does not 
record a confirmed gram-negative organism, so code J15.6 is not supported. Diagnosis J18.9 is a more 
appropriate code based on the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 8, 2022, to November 11, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on May 1, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that genetic testing is not 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. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate denial of the physicians services. Therefore, we decided that the Plan has to pay for 
physician's services provided on May 1, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87581, 87551, 87541, 87661, 87591, 87491, 
87481, 87511, 87651, 87640, 87641, 87150, 87500, and 87801, billed for date of service March 29, 2023. 
 
You asked the Plan to pay for procedure codes 87581, 87551, 87541, 87661, 87591, 87491, 87481, 87511, 
87651, 87640, 87641, 87150, 87500, and 87801. The Plan denied your request. The Plan says the services are 
not payable as 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, we have confirmed that codes 
87581, 87551, 87541, 87661, 87591, 87491, 87481, 87511, 87651, 87640, and 87641, are column II codes to 
column I code 87801. We have also confirmed that code 87150 is a column II code to column I code 87150. 
Based on the claim submitted, Medicare billing criteria have not been met. 
 
Medicare rules also say that the physician must clearly document, in the medical record, his or her intent that 
the test be performed. In this case, the documentation submitted does not contain a valid physician order or lab 
requisition for the specific testing (87500, 87801) provided. The medical records do not show the ordering 
physicians intent that the testing be performed. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87581, 87551, 87541, 87661, 87591, 87491, 87481, 87511, 87651, 87640, 87641, 87150, 
87500, and 87801, billed for date of service March 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9276 billed for date of service January 25, 
2023. 
 
You asked the Plan to pay for procedure code A9276. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A9276 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A9276 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A9276 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A9276 billed for date of service January 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy (37765, 37766). 
 
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 records do not show that you have a varicose vein greater than 4 millimeters. 
 
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 the documentation does not meet coverage criteria.  For tributary treatment such as stab 
phlebectomy to be considered medically necessary per coverage criteria, the veins to be treated need to be at 
least 4 mm in diameter.  As there is no documentation suggesting the size of the tributary veins, this criterion 
has not been 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stab phlebectomy (37765, 37766).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided on 
July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay more of this bill. 
The Plan denied your request. The Plan says your annual dental allowance amount 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 Plans 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 requested item or service was exhausted on date of service July 12, 2023. You are 
responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) and a core build-up (D2950) provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 10, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) under pressure, full body 
chamber, per 30-minute interval (G0277) and a physician or other qualified health care professional attendance 
and supervision of hyperbaric oxygen therapy, per session (99183). 
 
You asked the Plan to pre-approve HBO therapy. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the records do not show that the enrollee has 
had 30 days of wound care since revascularization. The enrollee has just been initiated on treatment for 
infection and have therefore not had 30 days of wound care since the infection has resolved. 
 
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 HBO therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee underwent a right great toe amputation on October 1, 2023, for a diabetic ulcer 
with osteomyelitis.  The wound did not heal. The enrollee was hospitalized in October for acute coronary 
syndrome and exacerbation of heart failure. During that admission, the enrollee had both coronary and 
peripheral revascularization, on or about October 24, 2023.  Debridement of the amputation wound site was 
performed on November 6 and November 13.  Antibiotics were started on November 13, because of a previous 
positive culture. The wound was deemed Wagner grade 3 as of November 13. Medicare criteria requires 
evidence of no improvement after 30 days of standard wound care, which includes antibiotics for infection. It 
has not been 30 days since the start of antibiotics. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) under pressure, full body chamber, per 30-minute interval 
(G0277) and a physician or other qualified health care professional attendance and supervision of hyperbaric 
oxygen therapy, per session (99183).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 18, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing is covered by Medicare and should be 
paid. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include 
the required unique identifier. 
 
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. 
 
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 lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided on May 18, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 10, 2023. 
 
You asked the Plan to pay for dental services. You say that your coverage was incorrectly cancelled. The Plan 
denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on July 
10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block injection. 
 
You asked the Plan to pre-approve genicular nerve block injection. You say that you are in pain, and this 
procedure is your last resort for relief without daily pain medicine. The Plan denied your request. The Plan says 
the requested procedure does not meet the necessary requirements for approval. 
 
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 genicular nerve block injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a genicular nerve block is considered experimental for knee pain. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve block injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve block injection.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on March 10, 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 payment of CPT 99284 is more appropriate. 
 
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 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 documentation does not 
support a high level of complexity for the medical decision making. 
 
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 emergency room services (procedure code 99285) rendered on March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found ultrasound-guided radiation therapy is 
approved by the Food and Drug Administration (FDA); however, billing for daily simple simulations and/or 
image-guided radiation therapy (IGRT) has not been established by published data or supported by consensus 
guidelines. Daily IGRT is not the standard of care and is not medically necessary for the enrollee, based on the 
submitted records.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound-guided radiation therapy.