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

 
We decided that the Plan has to pre-approve intensity modulated radiation treatment (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that that the IMRT is not reasonable and necessary, as the member's condition does not 
meet the Plan's policy. 
 
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 that this enrollee's situation is relatively uncommon (thoracic spine metastasis with locally 
advanced non-small cell lung cancer (NSCLC) to be treated in one field). IMRT is a standard of care for Stage 
III lung cancer which would have similar treatment fields as this enrollee. The treatment intent suggests a 
plausible, clinically significant benefit of IMRT over 3-dimensional conformal radiation with respect to normal 
tissue sparing. It is plausible that IMRT would be more beneficial to the enrollee than any other available 
standard 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 IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
intensity modulated radiation treatment (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 pay for procedure code 20936 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 20936. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 20936 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 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services (procedure code 
99239) rendered on January 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 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 99239 is "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 discharge summary did not 
clearly record the duration of the encounter. Therefore, the records do not sufficiently support that more than 
30 minutes of hospital discharge day management services were rendered in this case. 
 
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 hospital discharge day management services (procedure code 99239) rendered on January 26, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87641, and 87653 rendered on 
December 28, 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 these charges are not reimbursable separately. 
 
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 87150: 
 
Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or 
isolate, each organism probed 
 
CPT 87641: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, 
amplified probe technique 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
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 provider reported these 
procedures with modifier XU, to indicate an unusual non-overlapping service. The laboratory report does not 
include documentation to support this billed modifier. 
 
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, 87641, and 87653 rendered on December 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Novolog injection pre-filled pen. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has tried and failed Humalog, 
Insulin Lispro and Lyumjev. You also say that the Novolog pen filled cartridge is compatible. 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 a Novolog injection pre-
filled pen.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound-care supplies (A6010, A6196, A6222, A6403, 
A6446, A6449) provided on February 15, 2023. 
 
You asked the Plan to pay for wound-care supplies. You say that you have reported the items at issue correctly. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid, sufficiently specific proof of delivery for the supplies provided in this case. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for wound-care supplies (A6010, A6196, A6222, 
A6403, A6446, A6449) provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the destruction of premalignant lesions 
provided on December 20, 2022. 
 
You asked the Plan to pay for the office visit and the destruction of premalignant lesions. You say that you are 
appealing the denial with supporting documentation. 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 office visit and the 
destruction of premalignant lesions provided on December 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve EGD. 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 EGD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found an unremarkable histology from an EGD 2-years ago that does not of itself medically obligate 
surveillance, and no genetic testing that identified a genetic cancer syndrome to warrant a repeat EGD in the 2-
year interval. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EGD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve esophagogastroduodenoscopy (EGD) (43235).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory pathology services (88341, 88342, 88360, 88365, 
88381) billed for date of service June 2, 2021. 
 
You asked the Plan to pay for laboratory pathology services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that many of the diagnostic services provided by 
physicians/practitioners contain both a TC and a PC. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory pathology services have not been met. Specifically, the records suggest that these 
services were rendered in an inpatient setting. The procedure codes at issue have a professional/technical 
component indicator of 1. This means that these codes have a professional and technical component. These 
codes have not been billed with the appropriate modifier to indicate that they are for the professional 
component. Payment for the technical component of these codes is included in the payment to the facility and 
is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for 
laboratory pathology services (88341, 88342, 88360, 88365, 88381) billed for date of service June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression sleeves (A6549). 
 
You asked the Plan to pre-approve gradient compression sleeves. 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 wound care items are covered under certain 
circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of gradient compression sleeves have not been met. Therefore, we decided that the Plan does not have 
to pre-approve gradient compression sleeves (A6549).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ventricular assist device supplies to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve ventricular assist device supplies. You say that the hospital uses this 
provider. The Plan denied your request. The Plan says there are in-network providers than can supply the 
requested items. 
 
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 
ventricular assist device supplies to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 24, 2022, 
to December 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. 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 November 24, 2022, to 
December 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) for date of 
service February 6, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the device rendered 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. 
 
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 the pneumatic compression device (E0676) for date of service February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spine fusion surgery. 
 
You asked the Plan to pre-approve lumbar spine fusion. You say that lumbar spine fusion is a necessity for 
your care. The Plan denied your request. The Plan says lumbar spine fusion 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 lumbar spine fusion. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no evidence of a recent trial and failure of physical therapy for back pain. More 
conservative measures are 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 lumbar spine fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar spine fusion surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on February 23, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on February 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services related to Transcatheter Aortic Valve 
Replacement (TAVR) provided from August 9, 2021, to September 3, 2021. 
 You asked the Plan to pay for inpatient services related to TAVR. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this claim cannot be 
processed as the necessary clinical trial number is missing or invalid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that claim lines billed without an 8-digit clinicaltrials.gov identifier number shall be returned as 
unprocessable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient services related to TAVR have not been met. Specifically, these services were billed 
without a valid clinical trial number. Therefore, we decided that the Plan does not have to pay for inpatient 
services related to Transcatheter Aortic Valve Replacement (TAVR) provided from August 9, 2021, to 
September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty procedures (22514, 22515). 
 
You asked the Plan to pre-approve kyphoplasty procedures. You say that kyphoplasty procedures are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says kyphoplasty procedures 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 kyphoplasty procedures. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no evidence of a trial of a back brace for fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve kyphoplasty procedures (22514, 22515).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the pontic coded as D6240 for tooth space 25. We decided that the 
Plan does not have to pre-approve the crown described by code D6058 and the pontic for tooth space 24.   
You asked the Plan to pre-approve an abutment supported crown for tooth number 23 (D6058) and a pontic 
(bridge) for tooth spaces 24 and 25 (D6240).. You say that you feel that this is necessary and should be covered 
by your Plan.  The Plan says that there was a pontic placed less than five years ago meaning that it cannot be 
covered again at this time. In addition, D6058 is not the appropriate code for the planned service and was 
correctly denied.  
 
We decided that the Plan has to pre-approve the pontic coded as D6240 for tooth space 25.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Review of the documentation and claims history cited by the Plan, we find that the denial of this service is not 
supported. The service that was provided within the last five year for tooth space 25 was a retainer crown on 
top of a tooth. This tooth was subsequently extracted, and an implant was placed. This request is for a pontic on 
top of an implant, which has not been provided in the past. As such, the benefit for this type of service for this 
tooth space has not been exhausted. Therefore, we decided that the Plan has to pre-approve the pontic coded as 
D6240 for tooth space 25.  
 
We also decided that the Plan does not have to pre-approve the crown described by code D6058 and the 
pontic for tooth space 24. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The file does show that a pontic had been previously placed for tooth space 24. This is only covered once per 
tooth per lifetime. As such, the benefit for this service in this tooth space has been exhausted. In regard to code 
D6058, this service was requested to place a crown on top of an implant that was previously placed/approved. 
D6058 is not the appropriate code for this service. There is another code which is more appropriate to describe 
a crown being used as a retainer to support a fixed denture or bridge. Therefore, we decided that the Plan does 
not have to pre-approve the crown described by code D6058 and the pontic for tooth space 24. 
 
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.