Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on March 12, 2022, to March 23, 
2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing the claim payment denial. 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 home health care 
provided on March 12, 2022, to March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
November 22, 2022, and December 22, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like these claims to be 
reprocessed, as medical necessity has been met. The Plan denied your request. The Plan says charges for or in 
connection with services or supplies that are, as determined by the Plan, considered to be experimental or 
investigational are excluded from coverage under the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the 
unit are included in the rental allowance; there is no additional allowance for supplies. 
 We looked at the file and Medicare rules. The record shows that the enrollee received a neuromuscular 
stimulator rental on November 22, 2022, and December 22, 2022. Based on this information, we decided that 
Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on November 22, 2022, 
and December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
November 22, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like these TENS 
supplies to be reprocessed, as medical necessity has been met. The Plan denied your request. The Plan says the 
denial of the TENS unit supplies was appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the 
unit are included in the rental allowance; there is no additional allowance for supplies. 
 
 We looked at the file and Medicare rules. The record shows that the enrollee received a neuromuscular 
stimulator rental on November 22, 2022. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the electrical stimulator supplies (A4595) provided on November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
November 22, 2022, and December 22, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like these claims to be 
reprocessed, as medical necessity has been met. The Plan denied your request. The Plan says the denial of the 
TENS unit supplies was appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the 
unit are included in the rental allowance; there is no additional allowance for supplies. 
 
 We looked at the file and Medicare rules. The record shows that the enrollee received a neuromuscular 
stimulator rental on November 22, 2022, and December 22, 2022. Based on this information, we decided that 
Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on November 22, 2022, 
and December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an establishing office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an establishing office visit. You say that you were told this provider would 
be enrolling in your Plan. The Plan denied your request. The Plan says there are many other in-network 
providers who are available to you within the allowable mileage from your residence. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an establishing office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from December 13, 
2022, to December 16, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that they would not let you leave your home 
medications at the hospital. You also say that they therefore had to give you medications from the hospital 
while you were an inpatient there. The Plan denied your request. The Plan says the medication is not covered as 
a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from December 13, 2022, to December 16, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for ultrasound-guided breast cryoablation rendered on July 6, 2022. 
 
You asked the Plan to pay for the services. You say that medical records have been submitted for medical 
necessity. The Plan denied your request. The Plan says that this service is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case.   Our physician reviewer 
found that the enrollee has biopsy-proven infiltrating ductal carcinoma of the left breast. Ultrasound guided 
cryoablation was performed and documented in the report.  This procedure is commonly used in patients such 
as this with increased risk for surgical excision.  
 
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 
ultrasound-guided breast cryoablation rendered on July 6, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for urography, retrograde, with or without KUB rendered on November 15, 
2022. 
 
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 
code 74420 is "Urography, retrograde, with or without kidney, ureter, and bladder (KUB) x-ray." 
 
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 records support that CPT 74420 
was rendered in this case. The operative report indicates that both the retrograde procedure and interpretation of 
the findings were done on November 15, 2022. 
 
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 
urography, retrograde, with or without KUB rendered on November 15, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thyroid uptake study (78012). 
 
You asked the Plan to pre-approve a thyroid uptake study. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is 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 a thyroid uptake study. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the thyroid-stimulating hormone (TSH) is normal and hence no indication for uptake 
exists. 
 
   
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 thyroid uptake study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thyroid uptake study (78012).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on February 10, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 nursing facility visit 
provided on February 10, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is 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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found treatment guidelines do not consider proton therapy for prostate cancer to 
be experimental; however, any potential benefit or detriment of proton therapy over standard intensity-
modulated radiation therapy (IMRT) is an investigational question being pursue by clinical trials. IMRT with 
or without image-guide radiation therapy (IGRT) are also highly effective and well tolerated. To date, there are 
no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
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 beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-57 provided on September 20, 2022. 
 
You asked the Plan to pay for procedure code 99213-57. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99213-57 is included in the global 
surgery payment for procedure code 15004 provided on September 20, 2022. Separate payment cannot be made 
for procedure code 99213-57. Furthermore, the file shows that the evaluation and management services were 
provided on the same day as the minor surgery with modifier 57. Modifier 57 is not used with minor surgeries 
because the global period for minor surgeries does not include the day prior to the surgery, and the decision to 
perform the minor procedure is typically done immediately before the service. It is then considered a routine 
preoperative service and a visit or consultation is not billed in addition to the procedure. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99213-57 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99213-57 provided on September 
20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
December 12, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like the TENS supplies 
to be reprocessed, as medical necessity has been met. The Plan denied your request. The Plan says the denial of 
the TENS unit supplies was appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the 
unit are included in the rental allowance; there is no additional allowance for supplies. 
 
 We looked at the file and Medicare rules. The record shows that the enrollee received a neuromuscular 
stimulator rental on December 12, 2022. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the electrical stimulator supplies (A4595) provided on December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service December 
15, 2022. 
 
You asked the Plan to pay for the billed services. You say that it is difficult to achieve goals when claims are 
denied. The Plan denied your request. The Plan says the correct code was not 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 code G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show that only 9 
drug classes were tested. There is a more appropriate code available to describe the services provided.  
 Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code G0482 billed for date of 
service December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on  
January 11, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for 
this service.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910) provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA) (64635, 64636). 
 
You asked the Plan to pre-approve the RFA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet the criteria listed 
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 the RFA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the LCD requires the patient not have another 
probable pain generator and the patient has radiculopathy clearly documented. 
 
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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the radiofrequency ablation (RFA) (64635, 64636).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitation, and medical needs (combined complexity) does not require 
an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the 
enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be 
provided in a lower intensity and alternate setting such as in a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.