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

 
We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that this is medically necessary. The Plan denied your 
request. The Plan says that IMRT is not supported for early stages of glottic cancer. 
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found a study concluded that high-quality IMRT should be adopted as a new standard of care for the 
treatment of early glottic cancers. Guidelines state that the application of IMRT to other sites is evolving and 
may be used at the discretion of treating physicians. Therefore, IMRT would be within accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
intensity modulated radiation therapy (IMRT).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the sacroiliac (SI) joint arthrodesis. 
 
You asked the Plan to pre-approve  the sacroiliac joint arthrodesis. You say that  the SI joint arthrodesis is 
medically necessary. You say the enrollee is in a lot of pain.  The Plan denied your request. The Plan says the 
SI joint arthrodesis is not medically necessary. The Plan says the records do not show an absence of an 
alternative or contributing diagnosis that could be causing pain.  
 
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 sacroiliac joint arthrodesis. Our 
reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no Si joint instability, fracture or lesion. The SI joint fusion for degenerative 
back pain is considered an experimental surgery.  
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 sacroiliac joint arthrodesis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve  the sacroiliac (SI) joint arthrodesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollee's rehabilitation needs are not complex and admission into 
Long Term Acute Care Facility is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from August 8, 2022, to 
September 13, 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 there are disallowed charges on the itemized bill. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 documentation of ultrasound 
guidance for vascular access or catheterization was not found in the records, which were sometimes poor 
quality. There is additionally no documentation of an office/outpatient visit found in the records. 
 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 inpatient hospital services rendered from August 8, 2022, to September 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device (Vertiflex) (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the enrollee has failed conservative 
treatment. You also say this is a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied 
your request. The Plan says this type of back surgery is unproven. The Plan also 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 the Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental as more research is needed. Therefore, the 
reviewer found that the Vertiflex device is not medically reasonable or 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device 
(Vertiflex) (22869, 22870).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64450 and 76942 rendered on February 9, 
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 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 64450: 
 
Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch  
CPT 76942: 
 
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretatio 
 
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 procedure report does include 
sufficient documentation to support that CPT 64450 was separate from the anesthesia service. The report 
documents the block was not the primary anesthetic used for post-operative pain. However, the medical record 
did not include a report to support a separate procedure. In terms of CPT 76942, the procedure report does not 
include documentation of this procedure. 
 
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 64450 and 76942 rendered on February 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 
87801 rendered on February 28, 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 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.  
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 in terms of CPT 87801, the 
provider reported three units of service. This procedure code represents a multiple organisms panel. Only one 
unit of service would be billed for this procedure when the same methodology is performed. In terms of the 
other codes, the laboratory report does not include documentation to support the rationale of modifier XU - 
unusual non-overlapping service. Therefore, these codes cannot be verified. 
 
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 87150, 87481, 87641, 87653, 87798, and 87801 rendered on February 28, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate procedure. 
 
You asked the Plan to pre-approve the bone marrow aspirate procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the bone marrow aspirate procedure is not medically 
necessary. The Plan says the effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have 
not been demonstrated in the peer-reviewed literature.  
 
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 bone marrow aspirate procedure. 
Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the bone marrow aspirate is experimental when used as bone graft material. 
 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 bone marrow aspirate procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the bone marrow aspirate procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Global Reach hereditary cancer panel rendered on 
January 22, 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 more information is needed to consider this charge. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that family history of pancreatic or prostate cancer along with history of breast and ovarian cancers are 
important to consider when making a decision about genetic testing. In this case, the enrollee's age of 
diagnosis, unilateral location of breast cancer, and family history of cancers consisting of kidney and lung 
cancer do not qualify this to require genetic 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Global Reach hereditary cancer panel rendered on January 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 rendered on April 26, 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 Current Procedural Terminology (CPT) code 99204 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter." 
 
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 documentation supported a 
medically appropriate history and physical; however, the documentation did not support a moderate level of 
decision making or that the encounter duration was 45-59 minutes total to support CPT 99204. 
 
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 code 99204 rendered on April 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the ambulance transportations provided on March 15, 
2023. 
 
You asked the Plan to pay more for the ambulance transportations. You say that the patient was transported 
twice on the same day for the same service. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment per date of service, regardless of the number of trips.  
 
 
 The enrollee has been asked to pay $222.48, which is less than the standard copayment for the ambulance 
transportations. These services fall within the ambulance services benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to pay more for the ambulance transportations provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (D1392), tubing 
(A4616) (oxygen), per foot, and cannula, nasal (A4615). 
 
You asked the Plan to pre-approve the portable oxygen concentrator, tubing and cannula, nasal. You say that 
the enrollee is requesting a portable concentrator to reduce fall incidents from moving her current oxygen 
concentrator. You also say that the portable one, a backpack, would be much better for her to prevent this. The 
Plan denied your request. The Plan says the portable oxygen concentrator, tubing and cannula is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a portable oxygen system is covered if the beneficiary 
is mobile within the home for Groups I and II, and the qualifying blood gas study was performed while at rest 
(awake) or during exercise. 
 
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 a portable oxygen concentrator, 
tubing and cannula, nasal. Our reviewer says that the portable oxygen concentrator and supplies are not 
medically necessary. Our physician reviewer found the enrollee has no documentation to support the need for a 
portable oxygen concentrator. The documentation does not have compelling evidence provided to state that the 
fall was from a home oxygen concentrator. In addition, there is no arterial blood gas (ABG) or documented 
saturation to confirm a need for oxygen withing this chart. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the portable oxygen concentrator, tubing and cannula, nasal have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (D1392), 
tubing (A4616) (oxygen), per foot, and cannula, nasal (A4615).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 98 units of procedure code Q9966 rendered on April 5, 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 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 Q9966 is "Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml." 
 
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 do not 
support the use of Q9966 for 98 units. The medical records state that 98 units were held in reserve - meaning 
that 98 units were not used. 
 
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 98 units of procedure code Q9966 rendered on April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 31, 2023, by an OON 
provider.  
 
You asked the Plan to pay for medical services. You say that this was medically necessary. The Plan denied 
your request. The Plan says services provided by an OON provider are 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 at issue in this case is not a network provider with the Plan. We looked at this physician's review, 
the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medical 
services have not been met.  
 The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for medical services. Therefore, we decided that the Plan does 
not have to pay for medical services provided on January 31, 2023, by an OON provider.