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

 
We decided that the Plan does not have to pre-approve proton treatment delivery; intermediate (77523). 
 
You asked the Plan to pre-approve proton treatment delivery. 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 
proton beam radiation treatment (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 proton treatment delivery. 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 clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a 
possible advantage of this expensive therapy. The prior model policy stated in the treatment of prostate cancer, 
the use of proton beam therapy (PBT) is evolving as the comparative efficacy evidence is still being developed. 
In order for an informed consensus on the role of PBT for prostate cancer to be reached, it essential to collect 
further data, especially to understand how the effectiveness or proton therapy compares to other radiation 
modalities and emphasizes the need to enroll enrollees on studies. 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 image-guided radiation treatment (IMRT) is an investigational question. Nevertheless, it is not 
specified if a clinical trial review was sought or whether this insurer allows for clinical trial exceptions. The 
decision is unfavorable as the reviewer does not believe the LCD criteria is 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 proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery; intermediate (77523).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia (J0129). 
 You asked the Plan to pre-approve Orencia. You say that the request is medically necessary. The Plan denied 
your request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orencia. Our reviewer says that the 
criteria for coverage of Orencia have not been met. Our physician reviewer found the Plan requires a trial of 
Stelara before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the Plan's required drug would likely be less 
effective or have adverse effects 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 Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia (J0129).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87502 and 87798 billed for date of service 
May 9, 2023. 
 
You asked the Plan to pay for procedure codes 87502 and 87798. The Plan denied your request. The Plan says 
the claim is 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 code 87502 
is a column II code to column I code 87633. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
 
The rules also says that the physician must clearly document, in the medical record, his or her intent that the 
test be performed. The records in this case do not contain a valid physician order or lab requisition for the 
testing provided in this case. As such, the billed "not otherwise specified" code cannot be verified. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87502 and 87798 billed for date of service 
May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel provided on March 29, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing panel provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on July 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service 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 August 2, 2022, and 
January 17, 2023. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided 
on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on April 4, 2023, billed with 
codes 87481, 87653, 87640, 87471, 87641, 87500 and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on April 4, 2023, billed with codes 87481, 87653, 87640, 87471, 87641, 87500 and 87798.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain/ceramic crown for teeth #28 and #29. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the criteria for approval have not been met. 
 
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 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 services. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found that the provided 
records include the dental x-rays for the enrollee (provided on 10/11/2023), the proposed procedure codes with 
a written description of the proposed procedures with an itemized cost of the procedures as required by the 
health plan's supplemental dental benefit policy. The provided records meet the health plan's supplemental 
dental benefit policy requirements.  
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a porcelain/ceramic crown for teeth #28 and #29.  
 
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 pre-approve genetic testing services (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested 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 genetic testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records in this case do not document that the enrollee has had any cancer 
diagnosis which would meet the coverage criteria for the requested genetic testing services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing services (81479).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. Per the Medicare Benefit Policy Manual, the medical 
record overall significantly complies with the various documentation requirements for IRF admission (e.g., as 
best summarized by the provider's progress note on October 18, 2023).  Indeed, this enrollees condition is in 
fact complex and fragile, and they are demonstrably participating in and benefiting from IRF level services. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 02, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services were 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 psychotherapy provided 
on November 02, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on November 29, 2022, billed 
with codes 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641, 87651, 87798 and U0005. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on November 29, 2022, billed with codes 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 
87641, 87651, 87798 and U0005.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for intravenous (IV) infusion provided on 
May 01, 2023, to May 05, 2023. 
 
You asked the Plan to waive the coinsurance for intravenous (IV) infusion. You say that you were never 
advised that there would be a copayment or coinsurance you would be responsible to pay. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for intravenous (IV) infusion. This item/service falls within the 
Medicare Part B prescription drugs 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. The total coinsurance you owe is $3,255.75, which is 20% of the allowed 
amount for the Medicare Part B drug IV infusions ($3255.73 allowed per infusion x 20% = $651.15 per 
infusion x 5 infusions = $3,255.75). Therefore, we decided that the Plan does not have to waive the coinsurance 
for intravenous (IV) infusion provided on May 01, 2023, to May 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on September 22, 2022, and billed with codes 87481, 87640, 87798, 87653, and 81003. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing should be billed with a 
single panel code. The Plan denied your request. The Plan says this testing was medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on September 22, 2022, and billed with codes 87481, 87640, 87798, 87653, and 81003.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for these services. The Plan 
denied your request. The Plan says your maximum dental annual 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 maximum annual dental allowance amount of $3,500 was exhausted. Therefore, we decided that 
the Plan does not have to pay for dental services provided on March 25, 2023.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 19370. We decided that the Plan does not have to pay for 11970 and 
19371.  
 
You asked the Plan to pay for procedure codes 11970, 19370, and 19371 rendered on February 8, 2023.. You 
say that this should be paid for. The Plan says that the records do not support the services billed. 
 We decided that the Plan has to pay for 19370.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 19370 is "Revision of 
peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy." 
 
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 for CPT 19370. Our reviewer says that that the records 
do document revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial 
capsulectomy to support CPT 19370.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
19370.  
 
We also decided that the Plan does not have to pay for 11970 and 19371. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of the upheld codes is: 
 
CPT 11970: 
 
Replacement of tissue expander with permanent implant 
 
CPT 19371: 
 
Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents 
 
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 for CPT 11970 and CPT 19371. Our reviewer says that 
the provided operative note states that "almost complete" capsulectomies were performed. However, the 
records do not document that a complete capsulectomy was performed to support CPT 19371. Additionally, the 
records do not document replacement of a tissue expander with a permanent implant to support CPT 11970.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 11970 and 19371 have not been met. Therefore, we decided that the Plan does 
not have to pay for 11970 and 19371. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation at level L2. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee needs this all of these 
services. The Plan denied your request. The Plan says they did not find there was sufficient evidence or unique 
circumstances to allow for this exception. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a third level is deemed not medically reasonable and 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation at level L2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120), and prophylaxis (D1110) 
provided on August 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service 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 February 8, 2023, and 
May 16, 2023. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation (D0120), 
and prophylaxis (D1110) provided on August 21, 2023.