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

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service December 
24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the treatment provided substantiates the billed 
claim. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity.  
 
We find that CPT code 99285 is not supported in the medical record. The records show the enrollee presented 
with ankle pain and was found to have a fracture. The enrollee denied dizziness, chest pain, and shortness of 
breath. The records do not show that medial decision making of high complexity was provided. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service December 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 19, 2022, to 
July 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that your software vendor had an 
issue beyond your control. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from June 19, 2022, to July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you have been waiting for approval of a power wheelchair since September 2022. The Plan denied your 
request. The Plan says although there are three requested power options (tilt, recline and elevating leg rests), 
there is not a medical need to control these power options through the 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you have 4 out of 5 strength in your biceps 
and triceps. Our reviewer also found that you have adequate upper body strength to manage standard power 
drives. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that the member is living in a nursing home facility 
and there is no other doctor there. The Plan denied your request. The Plan says the enrollee must receive their 
care from a network provider (for more information about this, see Section 2 in Chapter 3). In most cases, care 
the enrollee receives from an out-of-network provider (a provider who is not part of the plans network) will 
not be 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 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), periodic oral 
evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided on March 13, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0274, D0120 and D1110. You say that 
you are already established with this dentist who is closer to home. You also say that you feel it is unfair to 
have to travel 18 miles away to see a dentist that is in-network. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), 
and prophylaxis - adult (D1110) provided on March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7. 
 
You asked the Plan to pre-approve the Dexcom G7. You say that this service is medically necessary. The Plan 
denied your request. The Plan says they made reasonable attempts to obtain medical records from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Dexcom G7 have been met. There 
were no medical records provided.  Without this necessary information, we are unable to determine whether the criteria for coverage have been 
met. The Plan has shown that they made reasonable attempts to obtain this necessary information. Therefore, 
we decided that the Plan does not have to pre-approve a Dexcom G7.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on November 4, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a specialist office visit. 
You say that you disagree with cost share. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $40 copayment for physician/practitioner 
services/specialist.  You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $40 copayment 
for a specialist office visit. The total allowed amount for the prescription drugs is $5,922.55. You are being 
asked to pay $1,184.51 ($5,922.55 x 20% = $1,184.51). The total amount you are being asked to pay is 
$1,224.51 ($1,184.51 + $40 = $1,224.51). 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 cost share for Medicare 
Part B prescription drugs and a specialist office visit provided on November 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for admission to an LTACH.  
 
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 that the enrollee continues to receive acute care services, and these have not been 
denied. The records do not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.   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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on March 1, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication was given by the doctor. 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 pay for self-administered drugs provided 
on March 1, 2023.  
 
Benefits for the medication 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a PET scan provided on September 1, 
2022. 
 
You asked the Plan to waive the copayment for a PET scan. You say that you disagree with the cost share 
applied to the claim. 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 20% 
coinsurance for each Medicare-covered medical supply, which includes chemical agents used in certain 
diagnostic procedures and a $125 copayment for Medicare-covered radiological diagnostic services, not 
including x-rays.  You have been asked to pay $785 for a PET scan. This total includes a $125 copayment for a PET scan and 
$660, which is 20% of the allowed amount for the chemical agent used in the procedure ($3,300 allowed x 20% 
= $660). This item/service falls within the outpatient diagnostic tests 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 a PET scan provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4267) for tooth #30 
provided on February 6, 2023. 
 
You asked the Plan to pay for the dental service. You say that you have $1,000 of coverage and the procedure 
was necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the guided tissue regeneration is not covered by the Plan. 
 
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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration (D4267) for tooth #30 provided on February 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation treatment (PBRT) (77525). 
 
You asked the Plan to pre-approve PBRT. You say that you are requesting reconsideration due to medical 
necessity. The Plan denied your request. The Plan says a review of the literature indicates that PBRT is not the 
standard of care for prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of proton therapy is an accepted radiation technology, which has proven efficacy and 
tolerability. Certain conditions such as base of skull chordomas and chondrosarcomas, and pediatric central 
nervous system (CNS) 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. This 
enrollee is being offered pelvic/prostate radiotherapy for high-risk disease. The bottom line is that proton 
therapy for prostate cancer is not experimental, and in fact is an accepted treatment approach. While the 
reviewer does not think that proton therapy is an experimental therapy, any potential benefit or detriment of 
proton therapy over standard intensity modulated radiation therapy (IMRT) is an investigational question. 
Other treatment approaches (IMRT +/- image-guided radiation therapy (IGRT)) are also highly effective and 
well tolerated. Thus, whether proton therapy affords a benefit over other standard approaches (IMRT/IGRT) 
for prostate cancer is an area of investigation and remains controversial. To date, there are no compelling data 
to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted 
standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely 
offer it to enrollees. The decision is unfavorable as the reviewer does not believe the LCD criteria are 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 PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation treatment (PBRT) (77525).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services are medically 
necessary. The Plan denied your request. The Plan says  you must be between 50 and 77 years of age. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee does not meet the age requirement. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BMP-2 allograft (20930). 
 
You asked the Plan to pre-approve BMP-2 allograft. 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 BMP-2 allograft. 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 compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested BMP-2 allograft 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 BMP-2 allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve BMP-2 allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar L1, L2, L3 kyphoplasty (22514, 22515 x2, 
J2001, Q9966, G8539). 
 
You asked the Plan to pre-approve lumbar L1, L2, L3 kyphoplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 lumbar L1, L2, L3 kyphoplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found detailed 
documentation is not evident regarding a compression fracture at each of the requested levels of L1, L2, and 
L3. There is no indication of worsening pain, a progression of the body height loss, greater than 25% vertebral 
body height loss in all of the requested levels, or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging (MRI) corroboration of retropulsion at L1. There is also plausible other causes of 
the back pain. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar L1, L2, L3 kyphoplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve lumbar L1, L2, L3 kyphoplasty (22514, 22515 x2, J2001, Q9966, 
G8539).