Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crutch substitute (E0118). 
 
You asked the Plan to pre-approve the crutch substitute. You say that this scooter was recommended by your 
surgeon because it is easier to move around, specifically after the surgery. The Plan denied your request. The 
Plan says a crutch substitute is not a covered benefit with Medicare. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-
approve the crutch substitute (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose external beam radiation therapy to the right foot for the enrollee.

You asked the Plan to pre-approve low dose external beam radiation therapy. You say that low dose radiotherapy is standard of care for treating osteoarthritis. The Plan denied your request. The Plan says that experimental services are not covered.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for low dose external beam radiation therapy. Our Medical Director states that the documentation is insufficient to support that Heelex low-dose radiation therapy is medically reasonable and necessary for the enrollee in this case, is at least as beneficial as existing and available medically appropriate alternatives and is expected to be safe and effective. Further investigation into the potential role in the treatment of osteoarthritis with modern low-dose radiation therapy is recommended. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of low dose external beam radiation therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of low dose external beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve low dose external beam radiation therapy to the right foot for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 6, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that 99100 should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says procedure code 99100 is 
considered bundled and not separately payable.  
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of intracardiac ischemia monitoring system, 
the Avertix Guardian System. 
 
You asked the Plan to pre-approve the Avertix Guardian System. You say that the Avertix Guardian System is 
medically necessary. The Plan denied your request. The Plan says the Avertix Guardian System 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 the Avertix Guardian System. Our 
reviewer says that the requested Avertix Guardian System is not considered medically reasonable and 
necessary in this case. Our physician reviewer found an exhaustive review of the current medical literature 
pertaining to the Avertix Guardian System confirms several observational studies suggesting clinical benefit. While the clinical studies led to the Food and Drug Administration (FDA) approval, the Avertix Guardian 
System remains the subject of studies assessing long-term efficacy, as well as randomized, controlled, blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. At the current time, the Avertix Guardian System is not medically 
necessary in 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 Avertix Guardian System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Avertix Guardian System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a CPAP backup battery. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says rules for payment for durable medical equipment have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway pressure 
(CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone-growth stimulator (E0747). 
 
You asked the Plan to pre-approve an electrical bone-growth stimulator. You say that the requested treatment is 
a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for coverage for an 
osteogenesis stimulator have not been met. 
 
The Plan must follow Medicare rules. The rules say that a non-spinal electrical osteogenesis stimulator is 
covered only if any of the criteria listed in the Medicare rules section of this letter are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an electrical bone-growth stimulator have not been met. Specifically, the record does not support that nine months have elapsed since the enrollee's surgery. Therefore, we decided that the Plan does not have to 
pre-approve an electrical bone-growth stimulator (E0747).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the cause of pain not clear. There is no magnetic resonance imaging (MRI) 
showing only Modic changes. 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a penile implant. 
 
You asked the Plan to pre-approve a penile implant. You say that a penile implant is medically necessary. The 
Plan denied your request. The Plan says the requested penile implant is not medically necessary. Based on the 
office records provided, the member is achieving satisfactory erections with oral medications. 
 
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 penile implant. Our reviewer says that 
the requested penile implant is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee with erectile dysfunction and achieving satisfactory erections with the use of Cialis 
and Viagra booster. The enrollee does not wish to try intracavernosal injections or a vacuum constriction 
device. A penile implant is not medically reasonable and necessary 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 a penile implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a penile implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99239 rendered from August 7, 
2022, to August 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 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 the denied codes is: 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
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 patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99239: 
 
Hospital discharge day management; more than 30 minutes 
 
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 not supported by the medical records. Our reviewer found that the medical records include a 
"progress note;" however, the records do not include sufficient documentation to verify the billed dates of 
service. The service date was not documented in the procedure report. Additionally, the records do not contain 
any documentation of hospital discharge day management. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99233 and 99239 rendered from August 7, 2022, to August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 14, 2023, billed 
with codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, & 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 14, 2023, billed with codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, & 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87481, 87798, 87801) provided on April 
26, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 87150, 87481, 87798, and 87801 is not supported in the medical record. Specifically, 
multiple unbundled codes were submitted for a single panel. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (87150, 87481, 87798, 87801) provided on April 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rituximab. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the medication. Our reviewer says that 
the request is not medically necessary. Our physician reviewer found that the initial request was denied because 
documentation did not show that the enrollee's platelet count was less than thirty thousand. The American 
Society of Hematology recommends corticosteroids alone rather than rituximab and corticosteroids for initial 
therapy. 
 
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 rituximab.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy provided from January 2, 2023, to 
January 30, 2023. 
 
You asked the Plan to pay for group psychotherapy. The Plan denied your request. The Plan says with the 
information we have, we cannot determine how the member came to the servicing provider, whether the billed 
services were actually performed, or that the services were medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of group psychotherapy have been met. 
Therefore, we decided that the Plan does not have to pay for group psychotherapy provided from 
January 2, 2023, to January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 22, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that multiplex tests must be billed with only one testing 
code.  
We looked at the file and Medicare rules. The file shows that the panel was not billed with one single testing 
code. 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 the laboratory services rendered on June 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy session provided on April 18, 2023. 
 
You asked the Plan to pay for psychotherapy session. You say that you are requesting reconsideration for the 
denied claim. 
 The Plan denied your request. The Plan says the provider is not credentialed to see Medicare patients. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare payment cannot be made to a provider 
that is not enrolled in the Medicare program. The rules also say that LPCs are not eligible to enroll in Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy session have not been met. Therefore, we decided that the Plan does not have to pay 
for psychotherapy session provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission in foreign country provided on June 23, 
2023, to June 25, 2023. 
 
You asked the Plan to pay for inpatient admission. You say that you feel it should be covered. The Plan denied 
your request. The Plan says it is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that, generally, items and services provided outside of 
the United States (US) are not covered. The only exceptions are emergency hospital services when the 
emergency occurred within the US, emergency/non-emergency hospital services when the foreign hospital is 
substantially closer or more accessible than the US hospital, or services provided on a ship docked at a US port 
or within US Territorial waters. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay 
for inpatient admission in foreign country provided on June 23, 2023, to June 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from April 26, 2023, to  
June 7, 2023.  
 
You asked the Plan to pay for psychotherapy. You say that the provider is under the supervision of a Licensed 
Clinical Social Worker as shown on the supporting invoices. The Plan denied your request. The Plan says the 
provider type is not eligible to participate in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a National Certified 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 National Certified Counselor. 
Medicare says that a National Certified Counselor is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from April 26, 2023, to 
June 7, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation provided January 26, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the services were medically 
necessary. The Plan denied your request. The Plan says a Licensed Professional Counselor is not eligible to 
enroll in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional 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 Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychiatric diagnostic evaluation 
provided January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 27, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee was residing in a nursing 
facility when services were provided. 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 the nursing facility care 
provided on June 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 Lidocaine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug administration provided on June 11, 2023. 
 
You asked the Plan to pay for the drug administration. You say that this service was billed correctly and was 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug administration 
provided on June 11, 2023.