Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda, carboplatin, docetaxel, intravenous (IV) granisetron, 
and fosaprepitant. 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has stage IA endometrial 
carcinosarcoma that is deficient in mismatch repair (MMR). Keytruda, carboplatin, docetaxel, intravenous (IV) 
granisetron, and fosaprepitant are not approved by the Food and Drug Adminstration (FDA) for the enrollee's 
diagnosis. However, the use is supported by the National Comprehensive Cancer Network (NCCN) guidelines 
for endometrial carcinoma. The requested regimen is reasonable and medically necessary and safe and effective 
for the enrollee 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Keytruda, carboplatin, docetaxel, intravenous (IV) granisetron, and fosaprepitant.  
 
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: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 00320. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 99100.  
 
You asked the Plan to pay for procedure codes 00320 and 99100 provided on March 23, 2023. You say that 
you would like the Plan to reconsider their denial of payment. The Plan says that the services are not covered. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 00320.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 00320.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for the services described by procedure code(s) 99100. 
 
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: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99223. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 99232.  
 
You asked the Plan to pay for procedure codes 99223 and 99232 provided from March 23, 2021, to March 25, 
2021. You say that you would like the Plan to reconsider their denial of payment. The Plan says that the 
services are not covered. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99223.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99223.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99232. 
 
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 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code on March 24, 2021, and 2 units of this code on March 25, 2021, 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 
99232 have not been met. Therefore, we decided that the Plan does not have to pay for the services described 
by procedure code(s) 99232. 
 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 pre-approve a cone beam CT capture (D0364). 
 
You asked the Plan to pre-approve D0364. You say that you need this dental work. The Plan denied your 
request. The Plan says the denied dental service is not a covered dental benefit. 
 
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 pre-approve a 
cone beam CT capture (D0364).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insert spine fixation device x1 unit and Arthrodesis, 
posterior or posterolateral technique, single interspace; lumbar (with lateral transverse technique, when 
performed) x1. 
 
You asked the Plan to pre-approve a Minuteman device. You say that requesting reconsideration, the member 
has tried steroid injections, radiofrequency ablation and physical therapy, none of these have relieved the 
member's pain. The Plan denied your request. The Plan says a review of the current medical literature indicates 
that this service is considered experimental and investigational as it is not identified as widely used and 
generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature 
published in the English language. 
 
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 Minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the FDA indicates that this device is not intended for stand-alone use. Furthermore, 
this request is for use of the device as a stand-alone procedure, not as part of a spine surgery. The North 
American Spine Society states that "no literature supports the use of interspinous fixation without performing 
an open decortication and fusion of the posterior bony elements or interbody fusion." The review has 
determined that the items/services at issue in this case 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 a Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an insert spine fixation device x1 unit and Arthrodesis, posterior or posterolateral 
technique, single interspace; lumbar (with lateral transverse technique, when performed) x1.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from June 29, 2022, to 
November 29, 2022. 
 
You asked the Plan to reimburse you for the psychotherapy. The Plan denied your request. The Plan says a 
Licensed Professional Counselor is not eligible to participate in Medicare and are not eligible to receive 
payment from a Medicare plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for psychotherapy provided from 
June 29, 2022, to November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit, therapeutic ultrasound, 
electrical stimulation and application of a modality to 1 or more areas; hot or cold packs provided from  
May 25, 2023, to June 6, 2023.  
 
You asked the Plan to pay for the office or other outpatient visit, therapeutic ultrasound, electrical stimulation 
and application of a modality to 1 or more areas; hot or cold packs. You say that you had to go see a 
chiropractor for the pain and after the treatment the pain was resolved. The Plan denied your request. The Plan 
says chiropractic services are clearly defined and specifically denied in the members evidence of coverage as 
covered only under specific conditions. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office or other outpatient visit, therapeutic ultrasound, electrical 
stimulation and application of a modality to 1 or more areas; hot or cold packs provided from May 25, 2023, to 
June 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on March 
11, 2023, billed with code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that this was billed with the correct code.  The 
Plan denied your request. The Plan says this claim was paid with code 99284 which is more appropriate based 
on the records.  
 
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 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 ED services as billed. Our reviewer says 
that the code 99285 is not supported in this case. Our reviewer found the enrollee presented with right flank 
pain for which Tylenol was given prior to discharge. The documentation supports an appropriate exam, but not 
an appropriate history or medical decision making of high level. 
 
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 ED services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) services provided on March 11, 2023, billed with 
code 99285.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481-59, 87491-59, 87563-59, 87640-59, 
87653-59, 87798-59, 87641, and 87500 billed for April 25, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87481-59, 87491-59, 87563-59, 87640-59, 87653-59, 87798-59, 87641, 
and 87500 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique. The definition of code 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. The definition of code 87641 is infectious agent detection by nucleic acid (DNA or 
RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), amplified probe technique. 
 
We find that CPT codes 87481-59, 87491-59, 87563-59, 87640-59, 87653-59, 87798-59, 87641, and 87500 are 
not supported in the medical record. Specifically, the records show that a panel was performed and there is a 
more appropriate singular code for the services. 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 pay for 
procedure codes 87481-59, 87491-59, 87563-59, 87640-59, 87653-59, 87798-59, 87641, and 87500 billed for 
April 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 25, 2023, 
through June 23, 2023.  
 
You asked the Plan to pay for the home health services. You say that this was billed correctly and should be 
paid.  The Plan denied your request. The Plan says the admission date billed on this claim is not correct. 
 
The Plan must follow Medicare rules. Medicare rules say that the admission date reported on a claim for home 
health services must be the same as the date for the first period of care. 
 
We looked at the file and Medicare rules. The Plan has shown that the Notice of Admission (NOA) for this 
enrollee was issued with an admission date of January 24, 2023, while the admission date on this claim is listed 
as January 25, 2023. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from May 25, 2023, through June 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs rehabilitation to allow her to 
continue living on her own. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
a SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is an 82-year-old female with systemic inflammatory response syndrome 
(SIRS), dementia, and a recent pulmonary embolism. From a nursing perspective, the enrollee received oral 
medications and had stable vital signs. Regarding rehabilitation services, the enrollee received physical 
therapy. She was at a moderate to maximal assist level with functional mobility. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, skilled therapy is not required on a daily basis. This enrollee does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure (22612). 
 
You asked the Plan to pre-approve a Minuteman procedure. 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 a Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. In addition, fusion indications within guidelines/literature for 
(existing or potential intraoperative) instability have not been documented and/or met in this case. In addition, there are multiple alternate pain generators plausibly significantly contributing to the clinical condition that 
have not been fully documented as having been excluded and/or ruled out. No compelling rationale is presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested Minuteman procedure 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 Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure (22612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pulp cap and core buildup for tooth #6. 
 
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. 
 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 Plan covers these services 
when the services are medically necessary and reasonable.  
 
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 the submitted records are inadequate to 
document dental necessity for the pulp cap and core buildup. The x-ray does not show that the tooth has 
extensive damage and loss of tooth structure close to the pulp that would require a pulp cap and core buildup to 
retain the bridge retainer crown. The services are therefore not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pulp cap and core buildup for tooth #6.