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

 
We decided that the Plan does not have to pre-approve proton beam treatment delivery; intermediate (77523). 
 
You asked the Plan to pre-approve proton beam treatment delivery. You say that requesting reconsideration 
because the service is covered by original Medicare. The Plan denied your request. The Plan says a review of 
the literature indicates that proton beam therapy 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 beam treatment delivery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the use of proton therapy is an accepted radiation technology, which has 
proven efficacy and tolerability. Certain conditions such as base of skull chordomas and chondrosarcomas, and 
pediatric central nervous system (CNS) malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal 
tissue. Most (or all) radiation oncologists believe that proton therapy has a role in the treatment of some cancer 
enrollees. Proton therapy is an accepted, safe and effective treatment modality for prostate cancer. 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. Nothing in the case file suggests that standard dosimetric constraints cannot be met with a non-proton-
based treatment, and it is not plausible that proton therapy would be needed. The decision is unfavorable as the 
reviewer does not believe the LCD criteria are 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 beam treatment delivery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam treatment delivery; intermediate (77523).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing billed for date of service March 23, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the test helps determine the best course of 
treatment. The Plan denied your request. The Plan says this is not an approved test. 
 The Plan must follow Medicare rules. Medicare rules say that NGS testing is only covered under certain 
medical indications.  
 
We find that the panel testing has not been FDA approved or cleared as a companion diagnostic. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the gene panel testing billed for date of service March 23, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. 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 Euflexxa. Our reviewer says that the 
criteria for coverage of Euflexxa have not been met. Our physician reviewer found you have not trialed one of 
the preferred viscosupplemental treatments such as Monovisc, Orthovisc, Synvisc or Synvisc-One. Step 
therapy, as outlined by the Plan, requires that one of these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered or that the Plan's additional required drug 
would likely be less effective and/or likely have adverse effects for you. Without the support of the 
documentation, Euflexxa is not approved as step criteria has not been 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine podiatry services rendered on September 29, 2022. 
 
You asked the Plan to pay for the services. You say that you are eligible for covered routine foot care. The Plan 
denied your request. The Plan says there are no comorbidities that allow for Medicare coverage for routine 
podiatric services. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit 
unless you have diabetic foot disease or some other condition that makes professional care of your feet 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C Plan was correct in denying the request to pay for the services. Our reviewer says that 
the services at issue in this case were not medically reasonable or necessary.. Our physician reviewer found that 
the enrollee does not have a covered indication for routine foot care. The medical documentation supports that 
this enrollee is suffering with hypertrophic toenails and calluses. In this particular case the medical 
documentation does not support that the enrolle is suffering with diabetes, vascular disease, or peripheral 
neuropathy. Furthermore, the medical documentation does not support that the enrollee is suffering with onychomycosis.. Therefore, we decided that the Plan does not have to pay for routine podiatry services 
rendered on September 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are non-weight bearing and require IRF services 
to regain your prior level of functioning. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the observational care evaluation and management services coded as 
99223 performed on date of service April 14, 2023, and 99233 performed on April 15, 2023. 
 
You asked the Plan to pay for 99223 and 99233. You say that 99223 and 99233 should be paid as billed 
because the enrollee was kept for observational care within the Emergency Department. The Plan denied your 
request. The Plan says that 99223 and 99233 are denied because they were billed with an inappropriate POS, 
23, indicating the Emergency Department. 
 
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 rules also say that the rate, facility or nonfacility, that a physician service is paid under the 
Medicare Physician Fee Schedule (MPFS) is determined by the Place of service (POS) code that is used to 
identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician 
practitioner (NPP) or other supplier.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The citations provided by the Plan are not sufficient to support their rationale for 
the denial of 99223 and 99233. We confirmed that 99223 and 99233 were billed with POS of 23, indicating the 
Emergency Department. None of the citations provided clearly disallowed payment for codes such as those 
billed when reported in POS 23. Records support that this enrollee received face-to-face encounters on April 
14, 2023, and April 15, 2023, in the Emergency Department, where records also document that the enrollee 
was held for observational care. Codes 99223 and 99233 are used to describe evaluation and management 
services provided during a hospital inpatient stay or observation care. Thus, POS 23 reflects the actual place 
where the enrollee received the observational care evaluation and management services. Therefore, we decided 
that the Plan has to pay for the observational care evaluation and management services coded as 99223 
performed on date of service April 14, 2023, and 99233 performed on April 15, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services provided on April 26, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the portable x-ray services. You say that these services were urgently needed, so 
this should be an exception to the Plan's authorization rules. The Plan denied your request. The Plan says 
unauthorized, non-plan 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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. You claim that this service was urgently needed. However, the records show that this was a scheduled 
service.  The records show that the services were actually requested a day prior to when they were rendered, 
which would negate the allegation of 'urgency." Medicare rules consider urgently needed care to be care that is 
'immediately required.'  A scheduled x-ray a day later cannot be considered immediately required. In addition, 
the actual order for the x-ray indicates that the priority for these x-ray services is routine, negating the 
contention of urgency. Further, Medicare urgent care rules state that when inside the service area, Plans are 
only required to pay for urgently needed care when the network is temporarily unavailable or inaccessible. 
(Please see Centers for Medicare and Medicaid Services, Internet-Only Publication 100-16, Medicare Managed 
Care Manual, Chapter 4, Section 20.2.) You have provided no evidence that the Plan's network was unavailable 
or inaccessible.  If there was adequate time to schedule the portable x-ray service at issue, then there was time 
to contact the Plan to see if Plan providers were available.  There is no such evidence that occurred. 
 
We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that 
the Plan does not have to pay for portable x-ray services provided on April 26, 2023, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this level of care. The Plan denied 
your request. The Plan says the enrollee does not have a medical complexity that requires IRF services, and the 
care can be safely met at another setting.  
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 25, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the records provided support payment. The Plan 
denied your request. The Plan says the coding of this claim is not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that these services are medically necessary. 
The Plan denied your request. The Plan says these services are no longer medically necessary. 
 
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 continued 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 you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(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 continued skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 16, 2021, to 
September 10, 2021. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the RAP pertaining to the services at issue was not submitted 
timely. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs must submit a RAP within five calendar 
days after the start of care and within five calendar days after the "from date" for each subsequent 30-day 
period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the case record does not support that the 
RAP was submitted within 5 calendar days after the start of care. Therefore, we decided that the Plan does not 
have to pay for home health services provided from August 16, 2021, to September 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the self-administered drugs provided in the 
hospital from February 4, 2023, to February 6, 2023. 
 
You asked the Plan to reimburse you for the hospital care. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. The Plan says you have been reimburse for all 
other services minus your applicable copayment. 
 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 reimburse you for the self-administered 
drugs provided from February 4, 2023, to February 6, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95870 for date of service March 31, 2023. 
 
You asked the Plan to pay for procedure code 95870. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are 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, the CPT Code Manual definition of code 95870 is needle electromyography; limited study of 
muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, 
cranial nerve supplied muscles, or sphincters. 
 
We find that CPT code 95870 is not payable as billed. Specifically, this service was billed with LT and RT 
modifiers. This code is not eligible for a bilateral modifier such as LT or RT. This code is for unilateral or 
bilateral needle electromyography. Therefore, this code with the LT and RT modifiers cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure code 95870 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 95870 for date of service 
March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the warranty (A9270) and the shipping 
cost (A9901) for a portable oxygen concentrator purchased on April 13, 2023. 
 
You asked the Plan to provide reimbursement for the warranty and shipping cost. You say that you are 
requesting reconsideration of the denied items. The Plan denied your request. The Plan says these items are not 
covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that items that do not contribute 
meaningfully to the treatment of an illness or injury, or the functioning of a malformed body member are not 
covered. 
 
The record shows the warranty and shipping costs are not covered as they are considered personal comfort 
items. Therefore, we decided that the Plan does not have to provide reimbursement for the warranty (A9270) 
and the shipping cost (A9901) for a portable oxygen concentrator purchased on April 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. 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 follows Medicare rules. Medicare rules say that monoclonal antibodies directed against amyloid for 
the treatment of AD is covered under certain circumstances. 
 
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 Leqembi. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case the enrollee is noted to have 
undergone Cerebrospinal fluid (CSF) testing but the results of said testing were not provided for review. The 
NCD requires "confirmed presence of amyloid beta pathology consistent with AD." In as much, based on the 
information provided it cannot be said that criteria for coverage have been met/satisfied in this case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi.