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

 
We decided that the Plan does not have to pre-approve special spine nerve blocker (63650, L8680). 
 
You asked the Plan to pre-approve special spine nerve blocker. You say that please see attached. You are 
appealing because the enrollee does have diagnosis radiculopathy, spinal stenosis, lumbar region with 
neurogenic claudication. The Plan denied your request. The Plan says the enrollee does not have a diagnosis 
that meets criteria for a spinal cord stimulator. 
 
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 special spine nerve blocker. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee has chronic low back pain. The diagnosis is listed as 
spondylosis. The enrollee has not had any spine surgery and does not have any other evidence based indication 
for a spinal cord stimulator. The enrollee does not have an accepted indication for a spinal cord stimulator trial. 
The request is 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 special spine nerve blocker have not been met. Therefore, we decided that the 
Plan does not have to pre-approve special spine nerve blocker (63650, L8680).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on April 
28, 2020. 
 
You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied 
your request. The Plan says that the billed services were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis 
provided to the enrollee on April 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on 
June 7, 2020. 
 
You asked the Plan to pay for the services. You say that the enrollee had multiple exams on this date of service. 
The Plan denied your request. The Plan says CPT code 71045 is a column II procedure to the column I 
procedure, 71046, and an appropriate modifier is needed to represent the services as distinct and separate. 
 
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, we have confirmed that code 71045 
has a bundled relationship with code 71046 and cannot be paid as billed. This code cannot be paid as a separate 
line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 71045) 
provided to the enrollee on June 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
facility on July 2, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you don't think that the Plan should 
have to pay for this. The Plan denied your request. The Plan says the correct copayment has been 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 a $50 
copayment for outpatient diagnostic tests/CAT scan/freestanding provider.  
 
You have been asked to pay a $50 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests/CAT scan/freestanding provider 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 a 
CT scan provided by a participating provider on July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate.  
 
Benefits for Methotrexate 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: Partially Favorable

We decided that the Plan has to pre-approve MRI of the thoracic spine. We decided that the Plan does not have 
to pre-approve MRI of the right shoulder.  
 
You asked the Plan to pre-approve the MRIs. You say that this is medically necessary. The Plan says that no 
clinical information has been received to establish medical necessity. 
 
We decided that the Plan has to pre-approve MRI of the thoracic spine.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 for MRI of the thoracic spine. Our reviewer says that 
the requested MRI is medically reasonable and necessary. Our physician reviewer found that a review of the 
ED intake notes demonstrate that you had a previously known thoracic spine fracture. In a patient with 
significant trauma and back pain, MRI of the thoracic spine is reasonable to evaluate the nature of thoracic 
spine injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the thoracic spine have been met. Therefore, we decided that the Plan 
has to pre-approve MRI of the thoracic spine.  
 
We also decided that the Plan does not have to pre-approve MRI of the right shoulder. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 for MRI of the right shoulder. Our reviewer says that 
this MRI is not medically reasonable and necessary. Our physician reviewer found that the original plan issued 
by the physician at the ambulatory care center was for MRI of the cervical and thoracic spine but not the right 
shoulder.  There was no right shoulder plain x-ray and the physical exam of the right shoulder was not well 
delineated. Thus, the medical necessity of the right shoulder MRI was not established 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the right shoulder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve MRI of the right shoulder. 
 
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 waive the coinsurance for a continuous passive motion exercise 
device (E0935) received from an out-of-network provider on October 18 to November 6, 2019. 
 
You asked the Plan to waive the coinsurance for a continuous exercise device. You say that you were told this 
item was covered by insurance. The Plan denied your request. The Plan says the correct coinsurance 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 50% 
coinsurance for Medicare-covered durable medical equipment when obtained out-of-network.  
 
You have been asked to pay $261.90, or 50% of the Plan-allowed amount of $523.80, for a continuous exercise 
device. A continuous exercise device falls within the "Durable Medical Equipment (DME) and Related 
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 coinsurance for a continuous passive 
motion exercise device (E0935) received from an out-of-network provider on October 18 to November 6, 2019.  
 
Your complaint about receiving erroneous or misleading information about cost-sharing from the provider 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the left hip MRI provided on February 7, 2020. 
 
You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says this services was not 
authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary. Medicare rules also say that plans may require enrollees to obtain authorization before receiving 
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 pay for the MRI. Our reviewer says that the 
requested left hip MRI is not medically reasonable and necessary. Our physician reviewer found that while the 
interpretation of the left hip showed some pathology, CMS requires a written order for each imaging 
examination to be present and signed by the referring physician. In addition, an authorization is required for 
each body part examined and this clearly is not the case for this individual. An order for MRI of the left hip is 
not found in the records. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for the left hip MRI provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided to the enrollee on August 27, 2019. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says the billed code does not appropriately reflect the services as provided by an RN. 
 
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 99350 is not supported in the medical record. Specifically, the services were provided 
by an RN, who is not considered a physician or advanced practitioner. Based on this information, we decided 
that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not 
have to pay for a home visit provided to the enrollee on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the bone growth stimulator you received 
on February 27, 2020. 
 
You asked the Plan to waive the coinsurance for the bone growth stimulator. You say that you are unable to 
afford this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 
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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the bone growth stimulator. The bone growth stimulator falls 
within the durable medical equipment 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 coinsurance for 
the bone growth stimulator you received on February 27, 2020.
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 member is stable enough to go to a skilled nursing facility. 
 
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 
is receiving appropriate care at the present acute care facility and when considered medically stable by the 
treating team will be an appropriate candidate for care at a less intense level. 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. 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99284) on 
January 31, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the Plan voided 
copayments for treatment related to COVID-19 effective February 4 to July 24, 2020. The Plan denied your 
request. The Plan says the correct copayment 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 a $90 
copayment for each emergency room visit.  
 
The Plan has waived copayments for treatment related to the COVID-19 pandemic from May 11 to at least 
September 30, 2020. The date of your emergency room visit is outside this timeframe. Therefore, you have 
been asked to pay a $90 copayment for an emergency room visit. An 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 an emergency room 
visit (99284) on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alarm device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is needed to help with potential falls. The Plan 
denied your request. The Plan says this is not part of the benefit package. 
 
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 an alarm device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that all the doctors agreed the enrollee would 
benefit best by going to an LTACH prior to going home. You say that the enrollee is not a good fit for a skilled 
nursing facility or home health at this time due to the intense monitoring that is required. The Plan denied your 
request. The Plan says the request 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 LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not currently 
available at the acute care hospital. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis provided on March 12, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1845). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says there is insufficient documentation to corroborate the service. 
 
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 L1845 is Knee orthosis, double upright, thigh and calf, 
with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with 
or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or 
otherwise customized to fit a specific patient by an individual with expertise.  
 
We find that CPT code L1845 is not supported in the medical record. Specifically, the orthosis provided after 
the procedure is not specified in the documentation. Based on this information, we decided that Medicare rules 
for coverage of the knee orthosis (L1845) have not been met. Therefore, we decided that the Plan does not have 
to pay for the knee orthosis provided on March 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye surgery you had on February 27, 
2020. 
 
You asked the Plan to waive the copayment for the eye surgery. You say that you had this surgery in an office, 
so this copayment is incorrect. The Plan denied your request. The Plan says you were charged this copayment 
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 $295 
copayment for surgery at an outpatient hospital.  
 
Records show that you had this surgery at the provider's location.  According to this provider's 
website, the surgery location is part of an outpatient hospital facility. You have been asked to pay a $295 
copayment for the eye surgery. 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 eye surgery you had on 
February 27, 2020.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the services that the enrollee needs can be provided in 
another setting. 
 
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 the review indicates that the enrollee still requires acute hospital level of care 
services and is receiving appropriate care at the present acute care hospital.  At the time of the request, the 
enrollee's status is stable and progressing. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital where the enrollee 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 long term acute care hospital (LTACH) services.