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

 
We decided that the Plan does not have to pre-approve posterior interspinous decompression spacer procedure. 
 
You asked the Plan to pre-approve posterior interspinous decompression spacer procedure. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services 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 posterior interspinous decompression 
spacer procedure. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has low back pain. The requested spacer 
is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet 
criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of posterior interspinous decompression spacer procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve posterior interspinous decompression spacer 
procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient facility fee provided on July
2, 2020.
You asked the Plan to waive the copayment for the outpatient facility fee. You say that you were told you
would only have a $30 copayment for an office visit. You say this additional separate charge of $209.24 should
be non-applicable since this was just a simple office visit. The Plan denied your request. The Plan says you
have been charged the correct cost sharing amount.
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 each Medicare-covered outpatient hospital services. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the
outpatient facility fee.
You have been asked to pay a $209.24 copayment for the outpatient facility fee. The outpatient facility fee falls
within the "Outpatient hospital 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 outpatient facility fee provided on July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rear basket for your power scooter. 
 
You asked the Plan to pre-approve a rear basket. You say that you need this to carry oxygen tanks. The Plan 
denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a rear basket for your power scooter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spiriva (J3535). 
 
You asked the Plan to pre-approve Spiriva. You say that Spiriva is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Spiriva (J3535).  
 
Benefits for Spiriva 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminectomy (63047, 63048) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the requested services are not supported. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The imaging studies 
do not show evidence of severe stenosis. There is no correlation between imaging and physical exam. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 a laminectomy (63047, 63048) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires rendered. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered because the TENS unit was purchased in the previous 
twelve months. 
 
The Plan must follow Medicare rules. The rules say that replacement of lead wires (A4557) more often than 
every twelve months would rarely be reasonable and necessary. 
 
We looked at the file and Medicare rules. The services at issue are replacement lead wires. The file shows that 
the TENS unit was purchased within the previous twelve months. 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 pay for the lead wires rendered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that the enrollee needs this item. 
The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The item at issue is not covered. Based on this information, we 
decided that Medicare rules for coverage of a power seat elevation feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services (CPT 95941 and CPT 95999) 
provided to the enrollee on April 21, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95941: 
 
Continuous intraoperative neurophysiology monitoring from outside the operating room (remote or nearby) or 
for monitoring of more than one case while in the operating room, per hour (List separately in addition to code 
of primary procedure) 
 
CPT 95999: 
 
unlisted neurological or neuromuscular procedure or service 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 
95941 has been replaced by G0453. Billing with CPT 95941 is not payable.  Billing G0453 should only note 
the time spent providing one-on-one oversight of enrollee at hand. Train of four testing is not separately 
payable, as it is considered part of the overall monitoring. There is no evidence that any other unaccounted for 
neurologic or neuromuscular procedure was performed.  Therefore, the billing of CPT 95941 and CPT 95999 is 
not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurophysiology services (CPT 95941 and CPT 95999) provided to the enrollee on April 21, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (92014) provided on August 
3, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not have to pay the 
copayment. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Medicare covered vision services provided at an out-of-network specialist's office.  
 
You have been asked to pay a $50 copayment for an office visit. The service at issue falls within the Medicare 
covered vision services provided at an out-of-network specialist's office 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 an office visit (92014) provided on August 3, 2020.  
 
Your complaint about potential misinformation that you received is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network benefit coverage with an out of network 
provider for outpatient mental health services to be provided by a Board-Certified Behavioral Analyst. 
 
 
You asked the Plan to pre-approve in-network benefit coverage with an out of network provider for outpatient 
mental health services to be provided by a Board-Certified Behavioral Analyst. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers and pays for services only when they 
are furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested provider at issue in this 
appeal is not Medicare-certified. Based on this information, we decided that Medicare rules for coverage of in-
network benefit coverage with an out of network provider for outpatient mental health services to be provided 
by a Board-Certified Behavioral Analyst have not been met. Therefore, we decided that the Plan does not have 
to pre-approve in-network benefit coverage with an out of network provider for outpatient mental health 
services to be provided by a Board-Certified Behavioral Analyst.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Craftmatic adjustable bed. 
 
You asked the Plan to pre-approve the bed. You say that you are in a lot of pain and have difficulty sleeping at 
night. The Plan denied your request. The Plan says the provider has opted out of the Medicare program. 
 
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 are to be provided provided in a non-urgent, non-emergent situation by the 
provider who has opted out of the Medicare program. The bed at issue in this case is also not primarily for a 
medical purpose. Therefore, we decided that the Plan does not have to pre-approve a Craftmatic adjustable bed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation services provided on 
March 4, 2019. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the psychiatric diagnostic evaluation services was not filed until September 
8, 2020. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation 
services provided on March 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialty absorptive dressing (A6253). 
 
You asked the Plan to pre-approve specialty absorptive dressing. You say that this should be covered because 
the enrollee's wounds have a lot of drainage. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that specialty absorptive dressings are covered when 
used for moderately or highly exudative full thickness wounds. 
 
We looked at the file and Medicare rules. The submitted medical records do not document that the enrollee has 
moderately or highly exudative full thickness wounds. Based on this information, we decided that Medicare 
rules for coverage of specialty absorptive dressing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve specialty absorptive dressing (A6253).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab. 
 
You asked the Plan to pre-approve Pembrolizumab. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says Pembrolizumab does not meet the 
NCCN guidelines and would be used as a first line treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pembrolizumab. Our reviewer says that 
first line Pembrolizumab is not compendia approved for penile cancer.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pembrolizumab.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve semi-electric hospital bed. You say that that this is medically necessary. The 
Plan denied your request. The Plan says that the record does not support the enrollee requires frequent or 
immediate position changes. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our reviewer 
says that the criteria for coverage of a semi-electric hospital bed have been met. Our physician reviewer found 
based on the enrollee's need for elevation of head of bed for sleep, debility, and immobility, the requested semi-
electric hospital bed is medically reasonable and necessary to prevent complications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of semi-electric hospital bed have been met. Therefore, we decided that the Plan 
has to pre-approve semi-electric hospital bed (E0260).  
 
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 the Ensure nutritional supplement. 
 
You asked the Plan to pre-approve the Ensure nutritional supplement. You say that you would like 
reconsideration because the Ensure is medically necessary for the member. The Plan denied your request. The 
Plan says this is not a Medicare covered benefit 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve the Ensure nutritional supplement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where he 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator (E0466) on July 4, 2020 and August 4, 
2020.  
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
You say that the claim should be paid. The Plan denied your request. The Plan says the physician order is 
invalid, therefore the billed service cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order to support medical necessity for the supplies provided in 
this case. The submitted order do not indicate what specific items being ordered and length of need for the 
product; therefore, the billed service cannot be verified. 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 the home ventilator (E0466) on July 4, 2020 and August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99335) provided on April 7, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit. You say that you provided medically necessary services in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained before non-
emergent care with an out-of-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 had network providers 
available who could have provided 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 domiciliary visit (99335) provided on April 7, 
2020 by an out of network (OON) provider.