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

We decided that the Plan does not have to pre-approve the Vertiflex surgical device. 
You asked the Plan to pre-approve the Vertiflex surgical device. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the Vertiflex surgery is experimental and 
investigational and not covered. 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex surgical device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex spacer is experimental. More research is needed to show 
safety and efficacy of the device. 
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 Vertiflex surgical device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex surgical device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on October 5, 
2019. 
 
You asked the Plan to waive the copayment for emergency care. You say that you received a bill and disagree 
with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct 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 $100 
copayment for emergency care.  
 
You have been asked to pay a $100 copayment for emergency care. Emergency care falls within the emergency 
care 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 emergency care provided on 
October 5, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
August 17, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were under the 
impression that you would not have a copayment for an emergency room 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 $90 
copayment per visit for Medicare-covered emergency care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the ?Emergency care? 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 
emergency room visit provided on August 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve B12 injections and syringes. 
 
You asked the Plan to pre-approve B12 injections and syringes. You say that you would like the Plan to cover 
B12 injections and syringes. The Plan denied your request. The Plan says this drug and syringes are not 
covered under your Medicare Part B 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 B12 injections and syringes.  
 
Benefits for B12 injections and syringes 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee has not completed the full course in the 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. The enrollee 
still requires acute hospital level of care services and 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. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
You asked the Plan to pre-approve IRF care. You say that the enrollee's current needs cannot safely be met at a 
lower level of care. The Plan denied your request. The Plan says there is no need for physician supervision 3 
times a week, or an intensive rehab therapy program. 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for scheduled aortic valve/aortic root replacement. His 
medical conditions are stable. The complexity of his nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services at a residential treatment facility. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested service is not covered 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient services are only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. The requested type of treatment is only covered by Medicare for 
inpatient hospital classified stay when ordered by a physician. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve medical services at a residential treatment facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy (97124), mechanical traction therapy 
(97012), and exercise therapy (97110) to be provided by a chiropractor. 
 
You asked the Plan to pre-approve massage therapy, mechanical traction therapy, and exercise therapy. You 
say that the enrollee needs these services to relieve her pain. The Plan denied your request. The Plan says these 
are not covered chiropractic services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve massage therapy (97124), mechanical traction therapy (97012), and 
exercise therapy (97110) to be provided by a chiropractor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an 
increase in involuntary movements associated with a neurologic condition. Medical conditions are stable. There 
are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires provided to the enrollee on September 16, 
2020. 
 
You asked the Plan to pay for the lead wires. You say that this should be covered by the Plan. The Plan denied 
your request. The Plan says that the claim denied correctly. 
 
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 relevant medical records which support medical necessity 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 the lead wires provided to the 
enrollee on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on the integumentary system on 
the extremities, anterior trunk and perineum (00400) provided June 15, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that please be aware that the procedure 
performed was completed on two separate locations which is indicated by both diagnosis codes used. Please 
review and reprocess your claims for payment. The Plan denied your request. The Plan says the claim lacks 
information or has submission/billing errors. Two or more diagnosis codes associated to it are mismatched. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code  is not supported in the medical record. Specifically, the provider billed 00400 with the 
diagnoses R22.31 (Localized swelling, mass and lump, right upper limb) and R22.32 (Localized swelling, mass 
and lump, left upper limb). There is a more appropriate diagnosis code that can be used to indicate a bilateral 
diagnosis. Based on this information, we decided that Medicare rules for coverage of the anesthesia services 
have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for procedures on 
the integumentary system on the extremities, anterior trunk and perineum (00400) provided June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you would not be 
able to participate in an intensive therapy program. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that you have a broken ankle, are living at home and receiving home health physical therapy. You have 
persistent weakness and pain. Your medical conditions are stable. The complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. There is not a reasonable expectation that you will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehab program. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lead wires provided on September 29, 2020. 
 
You asked the Plan to pay for lead wires (A4557). You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says a TENS device was purchased in the previous 12 months therefore the lead wires 
have been denied 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The record shows a TENS device was purchased on July 29, 2020 and records supporting the medical necessity 
of the additional lead wires were not submitted. Based on this information, we decided that Medicare rules for 
coverage of lead wires (A4557) have not been met. Therefore, we decided that the Plan does not have to pay 
for lead wires provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out of network (OON) 
hematology-oncologist. 
 
You asked the Plan to pre-approve the OON office visit. You say that you should have a grace period to 
continue seeing the requested OON provider. The Plan denied your request. The Plan says the services needed 
are available in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollee's needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 OON office visit. Our reviewer says 
that the criteria for coverage of OON care have not been met. Our physician reviewer found the enrollee can 
safely be transitioned to an in-network provider. There is nothing unique about the enrollee's condition that 
would make it medically necessary for her to continue care with the OON provider. The Plan has shown that 
they have specialists in network who have the qualifications and expertise necessary to meet the current 
medical Standards of Care required for treatment of the enrollee's condition. An in-network provider can order 
a phlebotomy. 
 
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 OON office visit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an office visit with an out of network (OON) hematology-oncologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records provided for review from the treating providers do not document 
failure of standard modalities and/or devices used in rehabilitation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found CPT code L8702  (powered upper extremity range of motion assist device, elbow, wrist, hand, finger, 
single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated) (MyoPro Orthosis) is not medically necessary. There is insufficient literature in the peer reviewed 
publications to assess safety, efficacy, long term outcomes or patient management associated with the use of 
the MyoPro Orthosis for upper extremity paralysis/paresis from conditions such as the enrollee's stroke. 
Therefore, per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), the requested orthosis is 
not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of 
a malformed body member. The MyoPro Orthosis is not the most appropriate available supply or level of 
service for the patient in question considering potential benefits to the patient. It is not known to be effective, 
based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The 
MyoPro is not in widespread use based on scientific evidence and not the standard of care for post stroke 
hemiparesis. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-
term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G orthotic device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for hearing aids (V5261) purchased. 
 
You asked the Plan to waive the cost-sharing for hearing aids. You say that you have not received your benefit. 
The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 25% 
coinsurance and any amount over $1,000 for hearing aids (2 every 3 years) purchased from an out of network 
provider.  
 
In this case, you purchased hearing aids from an out of network provider. You have been asked to pay $250 
coinsurance, or 25% of $1,000, as well as the balance over $1,000 for hearing aids. Hearing aids fall within the 
"Mandatory Supplemental Hearing Benefit HER833" 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 
cost-sharing for hearing aids (V5261) purchased.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99291, 93010) provided on May 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes". The CPT Code Manual definition of code 
93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only". 
 
We asked our coding 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 use 
of CPT codes 99291 and 93010 is not supported by the records provided. Our coding reviewer found that the 
medical records provided do not include documentation of total time spent providing "Critical Care, evaluation 
and management of the critically ill or critically injured patient; first 30-74 minutes", being performed on May 
4, 2020, therefore this service cannot be verified. Additionally, The medical records provided do not include 
documentation of an "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only", 
being performed on May 4, 2020, therefore this service cannot be verified. 
 
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 the services (99291, 93010) provided on May 4, 2020.