Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Bioengingeered skin substitute grafts (Q4196 and 15271). 
 
You asked the Plan to pre-approve the Bioengingeered skin substitute grafts. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
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 the Bioengingeered skin substitute 
grafts. Our reviewer says that the requested services are considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the standards of care for cases that failed the first line therapies, 
and to avoid extensive surgical procedures, the grafts at issue are 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 the Bioengingeered skin substitute grafts have been met. Therefore, we decided 
that the Plan has to pre-approve Bioengingeered skin substitute grafts (Q4196 and 15271).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation mileage. 
 
You asked the Plan to provide coverage for additional routine transportation mileage. You say that there are no 
contracted providers within 50 miles of the enrollee's home. The Plan denied your request. The Plan says the 
request exceeds the mileage limit. 
 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.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for additional routine transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and clinic visit provided on September 21, 
2022, by a chiropractor. 
 
You asked the Plan to pay for the outpatient visits. You say that this necessary chiropractic care should be 
covered. The Plan denied your request. The Plan says the services in this case are not covered when performed 
by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit and clinic visit provided on September 21, 2022, by a 
chiropractor.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (87804, 87811, 87880, 99283) 
provided on September 22, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this provider is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for emergency room services (87804, 
87811, 87880, 99283) provided on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoperative electroencephalogram (EEG) (95955) on 
November 7, 2022.  

You asked the Plan to pay for an intraoperative EEG. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says this was 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 pay for an intraoperative EEG. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this type of service has not been shown to be of any clinical utility in procedures 
involving the lumbar spine. This service could have otherwise been omitted without a change in outcomes for 
the enrollee during the course of their surgery. The services provided did not serve as any form of clinical 
utility. In as much the services as provided would have otherwise exceeded the member's clinical needs at the 
time they were provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intraoperative EEG have not been met. Therefore, we decided that the Plan 
does not have to pay for an intraoperative electroencephalogram (EEG) (95955) on November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service June 2, 
2022, to July 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the services should be paid. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service June 2, 2022, to July 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no high quality that this type of radiation therapy is needed or effective. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that for the palliative treatment of bone metastases, the use of IGRT is generally considered not 
medically necessary outside of a medically plausible rationale (i.e. prior radiation treatment, unusual anatomy). 
In this case, the intent is clearly palliative, and it is not clear what benefit IGRT would afford. It seems as 
though IGRT is simply being used as routine practice, as there does not seem to be any exceptional circumstances with this patient necessitating the need for IGRT. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTAC 
admission criteria under CMS guidelines and cannot currently be adequately cared for at a Skilled Nursing 
Facility. The Plan denied your request. The Plan says that the enrollee does not meet the guidelines. 
 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the health plan. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective internal radiation therapy (SIRT) services 
(79445). 
 
You asked the Plan to pre-approve SIRT. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational. 
 
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 SIRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is not evident that systemic options have become ineffective for the enrollee. In fact, the enrollee 
has just started a new systemic therapy on February 1, 2023. A March 22, 2023, computed tomography (CT) 
scan showed a radiographic response within the liver. The appeal letter does not address the need for radioembolization in the context of response to this new agent. Radioembolization, offered for routine 
treatment in a patient without chemorefactory liver metastases, would not be furnished in accordance with 
accepted standards. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SIRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve selective internal radiation therapy (SIRT) services (79445).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment management 
services provided on August 31, 2022. 
 
You asked the Plan to pay for remote physiologic monitoring treatment management services. You say that the 
services were 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 remote physiologic 
monitoring treatment management services provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and segmental 
pneumatic appliances (E0668, E0673) provided September 13, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that kindly find the 
attached supporting documents and process the claim for payment. The Plan denied your request. The Plan says 
this service is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) and segmental pneumatic appliances (E0668, E0673) 
provided September 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (25609) provided on November 23, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says the billed code is 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 is open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments.. 
 
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 surgical services. Our reviewer says that the provided 
records do not support the code billed. Our reviewer found the operative report does not state the number of fragments that were repaired with internal fixation. Per coding guidelines, this code requires internal fixation of 
3 or more fragments. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (25609) provided on November 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on January 12, 2023. 
 
You asked the Plan to pay for the medication. You say that this was medically 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 pay for self-administered drugs received 
on January 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Zofran. 
 
You asked the Plan to pre-approve the medication. You say that the drug should be covered. 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 the Zofran.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound-guided radiation therapy. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 ultrasound-guided radiation therapy. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that usually the requested services are used when critical structures are 
abutting or in close proximity to the target that is being treated to high doses. This situation does not apply to 
the enrollee in this case, for whom the target lesion can be seen on the skin to assist in daily set-up.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound-guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound-guided radiation therapy (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit you had on December 19, 2022. 
 
You asked the Plan to pay for the office visit. You say that the doctor is not an alternative medicine doctor, so 
this claim should be paid. The Plan denied your request. The Plan says the doctor you saw has opted out of 
Medicare, so this claim cannot be paid. The Plan must follow Medicare rules. The rules say that no Medicare 
payment may be made to a beneficiary for items or services provided directly by a physician or practitioner 
who has opted out of the program except in cases involving emergencies or urgently needed care. The services 
at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out 
of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit you had 
on December 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 28, 2022, to 
February 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you timely submitted the NOA, 
so this claim should be paid. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 28, 2022, to 
February 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 10, 2022, to 
April 8, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted for this claim. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 8, 2022. The NOA was not received by the Plan until June 2, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 10, 2022, to April 8, 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. 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity 
has not been established. Therefore, coverage criteria have not been met. 
 
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 insertion of interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found interlaminar distraction devices 
are experimental. More research is needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction 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.