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

 
We decided that the Plan does not have to pre-approve SpaceOAR gel. 
 
You asked the Plan to pre-approve SpaceOAR gel. You say that the enrollee has 1 cm space between prostate 
and rectum and he would benefit from spacer gel placement. You say that the enrollee is high risk and the 
highest risk patients benefit the most because they require intensification of treatment. You says that the 
enrollee does not have T3 disease and posterior extension and is an excellent candidate for spacer gel. The Plan 
denied your request. The Plan says the requested SpaceOAR gel is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SpaceOAR gel is covered when the criteria listed in 
the Medicare rules section of this decision 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 SpaceOAR gel. Our reviewer says that 
the requested SpaceOAR gel is not medically reasonable and necessary in this case. Our physician reviewer 
found that the requested SpaceOAR gel does not meet the Medicare LCD coverage criteria. The inclusion 
criteria require Low* or Favorable Intermediate Prostate Cancer Risk Group (AUA or NCCN criteria) and in 
this case the enrollee is considered high risk. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SpaceOAR gel have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SpaceOAR gel.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99306 and 99316 provided from March 23, 2023, to 
March 31, 2023. 
 
You asked the Plan to pay for procedure codes 99306 and 99316. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
supported. 
 
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. For procedure codes 99306 and 99316, the Plan denied payment because the 
medical records did not contain the name of the enrollee for verification. However, the file does show that 
additional records with the same information and the enrollee's name were provided. Since, the records that the 
Plan based their denial on had the same information as the records that included the enrollee's name and the 
Plan provided no other reasoning for the denial of payment, we must find in your favor. Therefore, we decided 
that the Plan has to pay for procedure codes 99306 and 99316 provided from March 23, 2023, to March 31, 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 21215 and 21470 rendered on June 8, 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 that the records do not support the services 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, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 21215: 
 
Graft, bone; mandible (includes obtaining graft) 
 
CPT 21470: 
 
Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, 
interdental fixation, and/or wiring of dentures or splints 
 
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 supported by the medical records. Our reviewer found that the enrollee underwent open 
reduction and internal fixation of the right mandibular non-union with a bone graft. The documentation 
describes a transcervical open surgical treatment for a complicated mandibular fracture with the use of grafting 
procedure; therefore, the documentation does support that CPT 21215 and 21470 were each rendered in this 
case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 21215 and 21470 rendered on June 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral enteral formula (B4152). 
 
You asked the Plan to pre-approve the oral enteral formula. You say that you want to appeal this denial. The 
Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that orally administered enteral nutrition products, 
related supplies and equipment will be denied non-covered, no benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oral enteral formula have not been met. Therefore, we decided that the Plan does not have to 
pre-approve oral enteral formula (B4152).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic footwear / foot orthotics.  
 
You asked the Plan to pre-approve diabetic footwear / foot orthotics. You say that you would like 
reconsideration because the requested diabetic footwear is medically necessary. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve diabetic footwear / foot orthotics.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital 
currently because of worsening chest findings on chest x-ray, with new right sided opacities concerning for 
multifocal pneumonia. 
 
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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, the tenotomy, and the debridement provided 
on April 18, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, the tenotomy, and the debridement. You say that you were not 
aware that there was a $2,500 limit on coverage when out of state. The Plan denied your request. The Plan says 
the benefit limit has been exhausted. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services. We found no exception that would require the Plan to pay for these services. The record shows that 
the benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the office visit, the 
tenotomy, and the debridement provided on April 18, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0239U billed with diagnosis codes C22.1 and 
C24.0 provided on May 2, 2023. 
 
You asked the Plan to pay for procedure code 0239U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that C22.1 has an Excludes1 note in relation to C24.0. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for procedure code 0239U have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 0239U billed with diagnosis codes C22.1 and C24.0 provided on May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for integrated biopsychosocial assessment provided on May 17, 
2023. 
 
You asked the Plan to pay for integrated biopsychosocial assessment. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for integrated 
biopsychosocial assessment provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 20, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that all records have been previously sent. The 
Plan denied your request. The Plan says insufficient information was provided to review this appeal. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 laboratory services have been met.  
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 20, 
2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for chemotherapy treatment, Nivolumab, provided on September 29, 2022. 
 
You asked the Plan to pay for Nivolumab. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that the services rendered do not meet the criteria to be 
approved. 
 
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 pay for Nivolumab. Our reviewer says that the 
chemotherapy treatment received meets the criteria necessary for approval. Our physician reviewer found the 
documentation provided shows no evidence the enrollee's disease has progressed while receiving Nivolumab. 
The requested use of Nivolumab is FDA-approved for the enrollee's diagnosis. The use of Nivolumab is safe 
and effective and otherwise reasonable and necessary for the 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 Nivolumab have been met. Therefore, we decided that the Plan has to pay for 
chemotherapy treatment, Nivolumab, provided on September 29, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on June 30, 
2023. 
 
You asked the Plan to pay for the chronic care management services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chronic care 
management services provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 23, 2023. 
 
You asked the Plan to pay for a home visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
May 23, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from December 28, 2022, 
to December 30, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that the post-surgical PT services were 
medically necessary. The Plan denied your request. The Plan says the maximum visits for PT have been 
reached. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
  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 physical therapy services have been 
met. The medical records required to perform the medical review were not provided. Therefore, we decided 
that the Plan does not have to pay for physical therapy services provided from December 28, 2022, to 
December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custodial care provided on July 4, 2022, to July 31, 2022. 
 
You asked the Plan to pay for custodial care. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for custodial care 
provided on July 4, 2022, to July 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, drug test, and telehealth originating site 
facility fee provided on February 10, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that this claim was filed timely. The Plan denied 
your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient services was not filed until May 10, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the office visit, drug test, and telehealth originating site facility 
fee provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #7, #8, #9, and #10 and a 
retainer crown (D6740) for tooth #6 and #11. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee declined a partial denture and 
only wants a bridge. The Plan denied your request. The Plan says the denial of authorization for the bridge is 
correct, because there was no documentation precluding the use of a removable prosthesis.  
 
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 the dental 
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 the dental services. Our reviewer says 
that the fixed bridge coverage criteria was not met. Our physician reviewer found that a fixed bridge may be 
considered for coverage to replace a single maxillary anterior tooth or if there is documentation precluding the 
use of a removable appliance. In this case there are 4 missing maxillary anterior teeth being replaced and no 
documentation precluding the use of a removable appliance. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic (D6245) for tooth #7, #8, #9, and #10 and a retainer crown (D6740) for tooth 
#6 and #11.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bacterial urine culture performed on May 16, 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 this was not done for a covered indication. 
 
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 pay for 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 specify how the criteria for urine culture are met and why it was 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a bacterial urine culture performed on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99358 and 99359 billed for date of service 
April 21, 2023. 
 
You asked the Plan to pay for procedure codes 99358 and 99359. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
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 codes 99358 and 99359 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99358 and 99359 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99358 and 99359 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99358 and 99359 billed for 
date of service April 21, 2023.