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

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF services are necessary to help the enrollee 
regain their strength and return to their baseline. The Plan denied your request. The Plan says the SNF services 
requested do not meet the requirements for approval.  
 
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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable gaseous oxygen system (E0431). 
 
You asked the Plan to pre-approve the portable gaseous oxygen system. You say that this service is a medical 
necessity. The Plan denied your request. The Plan says your records do not show the need for home oxygen. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable gaseous oxygen system Our 
reviewer says that the requested item is not medically reasonable or necessary Our physician reviewer found 
you do not have documented hypoxemia or laboratory data to determine the medical need for oxygen therapy. 
There was no arterial blood gas (ABG), saturation, or studies to confirm any benefit from oxygen therapy. 
Hence, you do not qualify for home oxygen. 
 
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 portable gaseous oxygen system have not been met.  Therefore, we decided 
that the Plan does not have to pre-approve a portable gaseous oxygen system (E0431).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transplant care to be provided by an OON provider.  
 
You asked the Plan to pre-approve transplant care provided by an OON provider. You say that the enrollee 
needs specialized care. The Plan denied your request. The Plan says the services are not authorized because the 
provider is out-of-network. The service can be provided by an in-network provider. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 transplant care provided by an OON provider. Our reviewer says that the 
seeing an OON provider is not medically necessary. Our physician reviewer found that as long as the plan can 
provide the same therapy, autologous stem cell transplantation, by an in-network provider then it is not 
necessary to see an OON provider. The Plan has provided the names of in-network providers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transplant care provided by an OON provider have not been met.  
 
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 transplant care provided by an OON provider. 
Therefore, we decided that the Plan does not have to pre-approve transplant care to be provided by an OON 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET)/Computed 
tomography (CT) scan.  
 
You asked the Plan to pre-approve a PET/CT scan. You say that the records provided support the need for the 
requested PET/CT scan. The Plan denied your request. The Plan says the requested PET/CT scan is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET/CT scan. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of essential 
thrombocythemia with positive JAK2 and elevated platelet count. The enrollee is an ex-smoker who had a low 
dose CT scan on May 16, 2023, demonstrating 3-millimeter (mm) subpleural nodular density and nodularity 
within the bilateral medial posterior pleura measuring up to 1.3 centimeters (cm). A contrast-enhanced CT as 
follow-up was recommended. A PET/CT scan was ordered to evaluate. A PET scan is not indicated at this time. Contrast-enhanced CT to follow-up on the lesion was recommended as the first follow-up study. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET)/Computed tomography (CT) scan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that the enrollee had left shoulder surgery on 
September 19, 2023, and cannot move that arm at all. The day after the surgery the enrollee was admitted to the 
emergency room for internal stomach bleeding. They have to follow a strict diet but cannot prepare food with 
one hand. The Plan denied your request. The Plan says the records provided do not support the medical 
necessity for home health aide visits. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that the clinical 
documentation does not specify any care plan in which the professional service of a skilled home health aide 
would be required. The clinical documentation does not specify any functional impairments and does not show 
that patient is home bound. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multiaxial ankle with the dorsiflexion feature (L5968) 
and a flex-walk system or equal (L5981).  
 
You asked the Plan to pre-approve the multiaxial ankle and the flex-walk system. You say that the enrollee's 
prosthesis has been changed to a K2 foot. The Plan denied your request. The Plan says the requested advanced 
foot with ankle feature exceeds the enrollee's needs. The Plan says that a new request for a prosthetic foot that 
meets the enrollee's needs and Medicare guidelines, has been requested by the enrollee's prosthetist for review. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the multiaxial ankle and the flex-walk 
system. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the requested items exceed the enrollee's functional need as the 
requested foot is a K3 foot/ankle and the vendor appeal letter states the foot has been changed to a K2 foot. 
 
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 multiaxial ankle and the flex-walk system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a multiaxial ankle with the dorsiflexion feature (L5968) and 
a flex-walk system or equal (L5981).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for March 11, 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 code 99285 is 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for these services. Our reviewer says that procedure code 99285 
is not supported. Our reviewer found the enrollee was evaluated in the emergency department (ED) with a history and physical examination, laboratory studies, and a computed tomography (CT) scan of the abdomen. 
There is no documentation of a high level of decision making in the submitted records; therefore, code 99285 is 
not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99285 billed for March 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
October 15, 2022, billed with code 99284. 
 
You asked the Plan to pay for the ED services as billed. You say that it is felt that this code was correct. The 
Plan denied your request. The Plan says the code assigned is not appropriate for the services rendered. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. 
 
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 99284 is not supported.  Our reviewer found the enrollee presented with hemorrhagic stroke. The 
documentation supports an appropriate exam, but not an appropriate history or medical decision making of 
moderate 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 October 15, 2022, billed with 
code 99284.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 12, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you have been credentialed with Medicare since 
July 1, 2022, and with the Plan since August 1, 2023. The Plan denied your request. The Plan says the provider 
is not a contracted provider with the Plan for Medicare lines of business. The tax ID that the provider is 
associated with, found on the claim image, is only showing participating contracts for commercial 
lines of business. The additional provider records found within the Plans systems are not showing active for 
the Medicare lines of business, terminating on July 28, 2022. Further, the providers primary specialty 
Counselor Addiction (Substance Use Disorder) is not eligible to enroll in Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that Substance Abuse Facility, Drug and Alcohol 
Rehabilitation 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 Substance Abuse Facility, Drug 
and Alcohol Rehabilitation Counselor. Medicare says that a Substance Abuse Facility, Drug and Alcohol 
Rehabilitation Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the 
Plan does not have to pay for psychotherapy provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve the requested SBRT. You say that SBRT is the most appropriate and 
effective treatment option available. The Plan denied your request. The Plan says there is not enough research 
showing the enrollee's type of cancer responds better to SBRT than to the standard treatment of three-
dimensional conformal radiation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested SBRT. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage 
policy, reflecting national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically necessary when the patient's performance status justifies aggressive treatment, and for 
those whose tumor burden can be completely targeted with acceptable risks. For metastatic disease, SBRT is 
generally only indicated for patients with oligometastatic disease or for those undergoing palliation after prior 
radiation. Oligometastases are defined as a state of metastatic disease with metastases few in number and 
extent. 
 
For this patient, the plan is to treat a mediastinal metastasis from colorectal cancer; other sites of metastases are 
well-controlled on systemic therapy (specifically a liver metastasis that has not been treated with radiotherapy 
in the past but has regressed).  
 
While SBRT for oligoprogression is an emerging approach it is not standard of care at this time and would not 
meet ASTRO model policy criteria which requires that all disease be safely encompassed in the treatment field. 
Additionally, SBRT would be quite risky in this patient with an ultracentral tumor. Patients with ultracentral 
tumors are at significant risk of severe to life threatening toxicity from SBRT, and in clinical situations for 
which SBRT is not well accepted. For these reasons, the requested SBRT is not medically reasonable and 
necessary for this patient. 
 
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 requested SBRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76000 billed for June 8, 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 the -59 modifier is not supported for code 76000.  
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 76000 is a column II code to column I code 31624; however, 76000 
was billed with a modifier.  
 
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 these services. Our reviewer says that the -59 modifier is not 
supported for code 76000. Our reviewer found the procedure report does not support a separate fluoroscopy 
procedure was performed. Bronchoscopy services include radiological services. The -59 modifier is not 
supported as a separate and distinct procedural service for code 76000. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76000 billed for June 8, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 96375. We decided that the Plan does not have to pay 
for procedure code 96374.  
 
You asked the Plan to pay for procedure codes 96374 and 96375 billed for date of service May 30, 2023. You 
say that 3 infusions were done. The Plan says that the codes are bundled into payment with code 96413 and not 
separately payable. 
 
We decided that the Plan has to pay for procedure code 96375.  
 
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 96375 is an add-on code that has been billed with appropriate 
primary procedure code, 96413. There are not PTP edits for this code pair. Based on the claim submitted, 
Medicare billing criteria have been met. Therefore, we decided that the Plan has to pay for procedure code 
96375 billed for date of service May 30, 2023.  
 
 
 
 
 
 
 
 
 
 We also decided that the Plan does not have to pay for procedure code 96374. 
 
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 96374 is a column II code to column I code 96413. The medical 
records provided do not show that code 96374 was a distinct procedural service. The records do not show that 
code 96374 was a different procedure not ordinarily encountered on the same day as code 96413.Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 96374 billed for date of service May 30, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Capecitabine. 
 
You asked the Plan to pre-approve Capecitabine. 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 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 Capecitabine. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the combination drug regimen has not 
been approved or supported by current evidence as a first line treatment option for metastatic breast cancer of 
this enrollee's stage and type. She has not yet had any treatment for her metastatic breast cancer. As standard first line treatment options for this enrollee's condition have not yet been tried and failed and due to the lack of 
FDA approval for this condition and lack of support for this drug regimen in current literature, approved 
compendia, and current guidelines, the request for Capecitabine will be considered not 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 Capecitabine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Capecitabine.