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

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22869). 
 
You asked the Plan to pre-approve a Vertiflex 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 has 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 25, 2020 to June 
29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that the enrollee is on a limited budget and you want 
some of these charges covered. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because this provider is out-of-network with the Plan and the enrollee could have been 
treated by an in-network provider. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 25, 
2020 to June 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the injections at C6-C7. We decided that the Plan does not have to 
pre-approve the injections at C4-C5 and C5-C6.  
 
You asked the Plan to pre-approve the injections. The Plan says that the injections are not medically necessary. 
 
We decided that the Plan has to pre-approve diagnostic branch blocks at C6-C7.  
 
The Plan follows Medicare rules. Medicare rules say that diagnostic blocks are covered for the above 
indications. 
 
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 injections. Our reviewer says that 
the requested injections are medically reasonable and necessary. Our physician reviewer found that only the 
 
 
new level of C6-C7 is medically reasonable and necessary as the previous injections did not provide relief at 
other levels. 
 
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 injections have been met. Therefore, we decided that the Plan has to pre-
approve the injections.  
 
We also decided that the Plan does not have to pre-approve diagnostic branch blocks at C4-C5 and C5-
C6. 
 
The Plan follows Medicare rules. Medicare rules say that diagnostic blocks are covered for the above 
indications. 
 
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 injections. Our reviewer says that 
the requested injections are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee had right-sided C3-C4, C4-C5 and C5-C6 diagnostic MBBs which did not produce pain relief. It is not 
medically reasonable and necessary to repeat failed blocks. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve . 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on May 7, 2020, and billed 
under code J3490. 
 
You asked the Plan to pay for code J3490. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) code J3490 remains not supported. 
The submitted medical records do not support the units billed. Also, the submitted medical records indicate that 
nutria-pharmaceutical blend was administered; therefore, each component of the blend cannot be billed 
separately. Therefore, the billed Healthcare Common Procedure Coding System (HCPCS) code and units 
cannot be verified. Of note, the appropriate unit for the nutria-pharmaceutical blend has already been 
processed; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to 
contact the provider for additional information. 
 
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, code J3490 cannot be paid as billed 
due to a billing error regarding a compounded drug. Medicare billing criteria are not met. Therefore, we 
decided that the Plan does not have to pay for services provided to the enrollee on May 7, 2020, and billed 
under code J3490.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the observation care provided from July 5, 
2020, through July 7, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Medicare-covered outpatient hospital observation services.  
 
You have been asked to pay a $250 copayment for the Medicare-covered outpatient hospital observation 
services provided. 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 observation care provided 
from July 5, 2020, through July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 4, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.  
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synisc One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary 
osteoarthritis of the knee. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, the Synvisc-
One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synisc One.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lower extremity vascular angiography 
(75716) provided March 11, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic services. You say that you do not understand 
why the insurance did not pay the fee. you cannot afford to pay this fee. The Plan denied your request. The 
Plan says the claim was processed and the correct copayment was applied per the plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $100 
copayment for x-ray services provide at outpatient hospital.  
 
You have been asked to pay $100 copayment for the diagnostic services. The diagnostic services fall within the 
Outpatient diagnostic tests and therapeutic services and supplies 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 lower extremity vascular angiography (75716) provided March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the composite fillings and amalgam fillings (D2331, 
D2332, D2150) provided on July 28, 2020. 
 
You asked the Plan to pre-approve the composite fillings and amalgam fillings. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says you have 
exhausted your benefit limit for these services. 
 
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. The Plan covers the composite 
fillings and amalgam fillings when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The record indicates that you previously had two fillings reimbursed 
for the 2020 calendar year prior to the July 28, 2020, date of service. Based on this information, we decided 
that the Plan's rules for coverage of the composite fillings and amalgam fillings have not been met.  Therefore, 
we decided that the Plan does not have to pre-approve the composite fillings and amalgam fillings (D2331, 
D2332, D2150) provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections (64493). 
 
You asked the Plan to pre-approve facet injections. 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 follows Medicare rules. Medicare rules say that facet joint injections are covered when specific 
criteria is met. 
 
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 facet injections. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found radiofrequency ablation (RFA) of the 
lateral sacral branches is considered experimental/ investigational due to the wide variation in efficacy in the 
peer reviewed literature. Therefore, the request is considered 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 facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections (64493).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically 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 admission to a LTACH is not medically necessary. Our physician reviewer found long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include ventilator support, tracheosotomy care, nebulizer treatment, intravenous antibiotics, 
surveillance laboratory studies, tube feedings, and therapy services. 
 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is 
with bilateral lumbar spine and buttock pain associated with neurogenic claudication secondary to lumbar 
spinal stenosis. The spacer device remains experimental. More research is needed to show safety and efficacy. 
There is no documented spinal instability. Hardware is not 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammography provided on 
September 4, 2020. 
 
You asked the Plan to waive the copayment for the service. You say that in the past when the member had a 
diagnostic mammogram they never had to pay. The Plan denied your request. The Plan says the claim was 
processed accordingly with the member's 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that member had a diagnostic mammography on September 4, 2020. The member is 
asked to pay a $50 copayment for the service. A screening mammography is used for the early detection of 
breast cancer in women who have no signs or symptoms of the disease. Once a history of breast cancer has 
been established, and until there are no longer any signs or symptoms of breast cancer, ongoing mammograms 
 
 
are considered diagnostic and are subject to cost sharing as described under Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies in the EOC. Therefore, the screening mammography annual benefits are not 
available for members who have signs or symptoms of breast cancer. 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 waive the copayment for diagnostic mammography provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 28, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on July 28, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve PET scan with concurrently acquired computed tomography (CT) 
for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the scan is necessary to review lung nodules 
found on a computerized tomography from December 4, 2020, which may be inflammatory or neoplastic. The 
Plan denied your request. The Plan says that the service is not reasonable and necessary under Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our physician reviewer 
found given the high risk of this patient for malignancy and the new findings on CT scan, this is a necessary 
and reasonable study. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve PET scan with concurrently acquired computed tomography (CT) for attenuation correction and 
anatomical localization imaging; skull base to mid-thigh (CPT Code 78815).  
 
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.