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

 
We decided that the Plan has to pay for procedure codes 82570, 84165, 83550, and 83880 provided on October 
20, 2022. 
 
You asked the Plan to pay for procedure codes 82570, 84165, 83550, and 83880. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are 
not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure codes 82570, 84165, 83550, and 83880 by a contract provider. The file 
does not show that the plan provided notice that procedure codes 82570, 84165, 83550, and 83880 would not 
be covered. Under Medicare rules, this means procedure codes 82570, 84165, 83550, and 83880 are considered 
approved by the plan. Therefore, we decided that the Plan has to pay for procedure codes 82570, 84165, 83550, 
and 83880 provided on October 20, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 28, 2023, to 
January 30, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided 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 January 28, 2023, to 
January 30, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the prior CT scan of the chest did not 
show a complete resolution of the centrilobular nodular infiltrate and right paratracheal lymphadenopathy. The 
Plan denied your request. The Plan says that a CT scan of the thorax is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the thorax. Our reviewer 
says that a CT scan of the thorax is medically necessary. Our physician reviewer found that the enrollee has a 
history of asbestos exposure and is more predisposed to pulmonary malignancy. Also, their CT scans in 2022 
showed mediastinal lymphadenopathy thought to be most likely reactive in nature especially in the face of 
inflammatory appearing infiltrates. While a chest x-ray would not allow for an adequate assessment of the 
lymphadenopathy and since peripheral infiltrates have been seen the performance of a 6-month surveillance CT 
is the best practice and should be approved. 
 
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 CT scan of the thorax have been met. Therefore, we decided that the Plan has 
to pre-approve a CT scan of the thorax.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CTA scan of the abdominal aorta. 
 
You asked the Plan to pre-approve a CTA scan of the abdominal aorta. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says that 
a CTA scan of the abdominal aorta is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CTA scan of the abdominal aorta. Our 
reviewer says that a CTA scan of the abdominal aorta is medically necessary. Our physician reviewer found 
that the enrollees ankle-brachial index of the right lower extremity was very abnormal. While the pressure in 
the right upper thigh could not be obtained the systolic pressure of the lower thigh was very elevated at 235 
millimeters of mercury. Also, this pattern may be seen with an obstructing lesion of the femoral artery and with 
a patient with a history of claudication the justification for a CTA is present. Therefore, the requested CTA of 
the aorta and runoff should be approved. 
 
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 CTA scan of the abdominal aorta have not been met. Therefore, we decided 
that the Plan has to pre-approve a CTA scan of the abdominal aorta.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician office visits to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physician office visits. You say that the OON provider is the only person 
that the enrollee wants to see. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physician office visits 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 home health services provided from April 25, 2022, to May 
21, 2022. 
 You asked the Plan to pay for the home health services. You say that the payment for this claim should have 
just been reduced, not denied in full. 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 April 25, 2022. The NOA was not received by the Plan until June 22, 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 
April 25, 2022, to May 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
services requested are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 continuous glucose monitor (CGM). 
Our reviewer says that the service is 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 a continuous glucose monitor (CGM) have been met. Therefore, we decided 
that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that a ventilator is necessary for the enrollee's ongoing 
care and clinical stability. The Plan denied your request. The Plan says a ventilator is not covered by Medicare 
for this purpose and the enrollee has not failed use of a bilevel positive airway pressure (BiPAP) device with 
volume assured pressure support (VAPS) mode. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code s9328 billed for date of service November 
16, 2022 to November 30, 2022. 
 
You asked the Plan to pay for procedure code s9328. You say that previous claims have paid for this procedure 
code. 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 date of service November 16, 2022 to November 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 25 home health skilled nursing visits, 25 physical 
therapy visits, 25 occupational therapy visits, and 25 home health aide visits. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary for the enrollee 
to continue home health services. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that based on 
the documentation provided, the Plans denial should be upheld. The enrollee does not have documented 
skilled nursing needs. The enrollee does not have documented skilled therapy needs. As such, the requested, 
ongoing home health services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 25 home health skilled nursing visits, 25 physical therapy visits, 25 occupational 
therapy visits, and 25 home health aide visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart 
 
You asked the Plan to pre-approve the CT scan. You say that you are aware of genetic coronary heart disease 
and the requested CT scan is needed to monitor your condition. The Plan denied your request. The Plan says 
CT calcium scoring is not covered by Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that the rules state that quantitative calcium scoring is 
not a covered service and will be denied as not medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
CT scan of the heart.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee has only been given a 
diagnosis of AD. There was no indication provided that the enrollee met diagnostic criteria for both AD and 
FTD. Nor was there any indication that FTD was suspected. In as much the baseline criteria for coverage of 
this service would not have been met. 
 
   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the enrollee had imaging done on 
October 12, 2022, which indicated there needs to be a 6 month follow up exam regarding pulmonary nodules. 
You say that a CT scan of the chest was recommended.  The Plan denied your request. The Plan says a CT scan 
of the thorax is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the thorax. Our reviewer 
says that a CT scan of the thorax is not medically necessary. Our physician reviewer found that the report 
authored by the radiologist on October 12, 2022, does not include a size measurement of pulmonary nodule. 
Although the published guidelines are designed around the actual size measurement of a pulmonary nodules the 
accepted recommendation for surveillance in this case are impossible to determine. Therefore, the requested 
CT scan of the thorax is not 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 a CT scan of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the thorax.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival flap (D4241) and the apically positioned flap 
(D4245) for tooth #5 provided on February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that the procedures were medically necessary and 
you would like the Plan to cover them. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the gingival flap and the apically positioned flap are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival flap (D4241) and the apically positioned flap (D4245) for tooth #5 provided on February 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has serious life threatening acute 
medical issues that are below the baseline and requires interdisciplinary therapy care. The Plan denied your 
request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have intensive rehabilitation needs and their medical needs do 
not require an inpatient hospital stay to meet rehabilitation goals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty surgery. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee has surgery scheduled. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery is only covered if certain 
indications are met and the enrollee does not have a contraindication to the surgery. 
 
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. Our reviewer says that the 
enrollee does not meet criteria for this surgery. Our physician reviewer found there is no trial of bracing. 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty surgery.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayments for the radiation therapy treatments provided on May 
11, 2022. We also decided that the Plan does not have to waive the copayment for the radiation therapy 
treatment provided on May 12, 2022.  
 
You asked the Plan to waive the copayments for the radiation therapy treatments. You say that you met your 
maximum out-of-pocket amount. The Plan denied your request. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to reduce the copayments for the radiation therapy treatments provided on 
May 11, 2022.  
 
You have been asked to pay a $80 copayment for the radiation therapy provided on May 11, 2022. You have 
also been asked to pay a $320 copayment for the radiation therapy provided on May 11, 2022. Based on the 
Plans Evidence of Coverage you cannot be asked to pay more than a $60 copayment for each radiation 
therapy. Therefore, we decided that the Plan has to reduce the copayments for the radiation therapy treatments 
provided on May 11, 2022.  
 
We also decided that the Plan does not have to waive the copayment for the radiation therapy treatment 
provided on May 12, 2022. 
 
The record also shows you had not met your maximum out-of-pocket prior to receiving these services. You 
have been asked to pay $59, which is less than the standard copayment for the radiation therapy treatment 
provided on May 12, 2022. This item/service falls within the outpatient diagnostic testing and therapeutic 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the radiation therapy 
treatment provided on May 12, 2022. 
 
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.