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

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
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 pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found SBRT with high fractional doses of one to 
five fractions is an established approach for the treatment of discrete lesions from cancer. 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 patients performance status justifies aggressive treatment, and for those whose tumor burden can be 
completely targeted with acceptable risks. The use of SBRT to one site of oligoprogression in an adrenal gland 
is considered furnished in accordance with accepted standards of medical practice, acknowledging that the data 
supporting this treatment continue to arise. The services are therefore reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve stereotactic body radiation therapy (SBRT).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided from 
May 8, 2023, to May 18, 2023, and an inpatient rehabilitation stay provided from May 18, 2023, to June 1, 
2023.  
 
You asked the Plan to waive the copayments for an inpatient hospital stay, and an inpatient rehabilitation stay. 
You say that you disagree with the copayments. 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 a $325 
copayment per day, for days 1 to 6 and a $0 copayment for additional days of each in-network Medicare-
covered hospital admission. You have been asked to pay a $325 copayment per day, for days 1 to 6 of the inpatient hospital stay provided 
from May 8, 2023, to May 18, 2023. You have been asked to pay a total of $1,950 for the inpatient hospital 
stay ($325 copayment x 6 days = $1,950). You have not been charged for any additional days. You have also 
been asked to pay a $325 copayment per day, for days 1 to 6 of the inpatient rehabilitation stay provided from 
May 18, 2023, to June 1, 2023.  You have been asked to pay a total of $1,950 for the inpatient rehabilitation 
stay ($325 copayment x 6 days = $1,950). You have not been charged for any additional days. These 
items/services fall within the inpatient hospital care 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. Therefore, we decided that the Plan does not have to waive the 
copayments for an inpatient hospital stay provided from May 8, 2023, to May 18, 2023, and an inpatient 
rehabilitation stay provided from May 18, 2023, to June 1, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Single Photon Emission Computed Tomography 
(SPECT) scan. 
 
You asked the Plan to pre-approve a SPECT scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules.  
 
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 SPECT scan. Our reviewer says that 
there is insufficient documentation to support the medical necessity for the requested SPECT test in this 
enrollees clinical management. Our physician reviewer found there is no documentation that the ECG shows 
an uninterpretable pattern. There is no evidence provided that would support the need for radionuclide stress 
testing. 
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Single Photon Emission Computed Tomography (SPECT) scan.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you require additional trips in order 
to receive your cancer treatment. The Plan denied your request. The Plan says the service is a covered benefit, 
but you have met the Plan limits which have been set in the subscriber agreement. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 5, 2023, billed with 
procedure code Q5106 (80 units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 Q5106 is Injection, epoetin alfa-epbx, biosimilar,1000 
units. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the documentation in the case file 
does not contain any information for the date of service in question. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 5, 2023, billed with procedure code 
Q5106 (80 units).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate sedation services. 
 
You asked the Plan to pre-approve moderate sedation services. You say that the precarious location of the 
nerves being addressed, and the vertebral artery necessitates the enrollee be immobile. You say that any 
movement increases the risk for arterial damage which could lead to permanent paralysis. The Plan denied your 
request. The Plan says moderate sedation 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 moderate sedation services. Our 
reviewer says that moderate sedation services are not medically necessary. Our physician reviewer found that 
there is no documentation of obstructive sleep apnea, morbid obesity, psychiatric issues, or spasticity. Also, 
there is no indication documented that requires anesthesia personnel. Therefore, the request is 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 moderate sedation services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve moderate sedation services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bevacizumab-awwb. 
 
You asked the Plan to pre-approve the medication. You say that this multi-drug combination could potentially 
prolong the enrollee survival while optimizing quality of life. The Plan denied your request. The Plan says that 
the requested use of this drug combination is not supported. 
 
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 the medication. Our reviewer says that 
that the requested drug combination is not FDA approved for the enrollees diagnosis. Our physician reviewer 
found that the use of bevacizumab-awwb is also not supported by one of the major drug compendia or by 
clinical research.  
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bevacizumab-awwb.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and a full leg segmental pneumatic appliance to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 
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 
a pneumatic compressor (E0651) and segmental pneumatic appliance for use with pneumatic compressor, full 
leg (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the wound care supplies billed for date of service February 18, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the 
documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
We looked at the file and the rules. The record does contain a valid physician order and proof of delivery. The 
tracking number on the supply order, which does include the enrollees name, is consistent with the tracking 
number on the delivery ticket. A review of the file does not reveal any reason that the required documentation 
is invalid. Therefore, we decided that the Plan has to pay for the wound care supplies billed for date of service 
February 18, 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: Favorable

 
We decided that the Plan has to pay for procedure code 93970 rendered on April 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 93970 is "Duplex scan of extremity veins including responses to compression and other maneuvers; 
complete bilateral study." 
 
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 there is a report of a bilateral lower 
extremity ultrasound within the submitted records and dated April 12, 2023. CPT 93970 is therefore 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 the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 93970 rendered on April 12, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve swingaway, detachable footrests, replacement only 
(K0052 x2), lower extremity custom footplate pads (K0108), custom lower extremity support (K0108), custom 
fabricated wheelchair back cushion (E2617), and repair or nonroutine service for durable medical equipment 
other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes (K0739 x7). 
 You asked the Plan to pre-approve detachable footrests, lower extremity custom footplate pads, custom lower 
extremity support, custom fabricated wheelchair back cushion, and repair or nonroutine service for durable 
medical equipment. 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. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of detachable footrests, lower extremity custom footplate pads, custom lower extremity support, 
custom fabricated wheelchair back cushion, and repair or nonroutine service for durable medical equipment 
have not been met. Therefore, we decided that the Plan does not have to pre-approve swingaway, detachable 
footrests, replacement only (K0052 x2), lower extremity custom footplate pads (K0108), custom lower 
extremity support (K0108), custom fabricated wheelchair back cushion (E2617), and repair or nonroutine 
service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor 
component, per 15 minutes (K0739 x7).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal test (81479) provided February 16, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting review of these 
documents and full allowance of the contracted or list price for Guardant Reveal against the enrollee's in-n 
benefits. The Plan denied your request. The Plan says Medicare does not cover services that are investigational 
due to unproven safety or efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Per DEX Diagnostics Exchange Registry, Guardant Reveal is not 
covered by Medicare. Per National Comprehensive Cancer Network (NCCN) Guidelines for Colon Cancer, 
Version 2.2023, there is insufficient data to recommend post-surgical ctDNA to estimate risk of recurrence or 
determine adjuvant therapy. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant Reveal test (81479) provided February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for code 99223. You say that this service was coded appropriately. The Plan denied 
your request. The Plan says code 99223 is not supported by the medical record. The records don't support a 
comprehensive history and medical decision making of high complexity. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history, 
a comprehensive exam, and medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not supported by the medical records. Our reviewer found the documented history is problem-focused.  The 
documented examination is not comprehensive.  The medical decision making is not of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service July 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that appropriate home health physical therapy goals have been met, thus the records do 
not show that 12 additional physical therapy sessions in the home setting would be required to effectively 
provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code T2003. 
 
You asked the Plan to pre-approve procedure code T2003. You say that the services are necessary. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code T2003 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2003 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T2003 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code T2003.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation, vasopneumatic devices, and 
subcutaneous vitamin injections provided on July 18, 2022.  
 
You asked the Plan to pay for electrical stimulation, vasopneumatic devices, and subcutaneous vitamin 
injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the 
services are not a covered benefit. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of electrical stimulation, vasopneumatic devices, and subcutaneous vitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation, vasopneumatic 
devices, and subcutaneous vitamin injections provided on July 18, 2022.