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

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder. You say that the loop recorder is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an implantable loop recorder is used when syncope is 
thought to be cardiac related but is too infrequent to be detected by either a Holter monitor or a traditional pre-
symptom loop recorder. 
 
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 implantable loop recorder. Our 
reviewer says that the requested procedure is not medically necessary. Our physician reviewer found there is no 
documentation provided to suggest a history of cryptogenic stroke or any other apparent indication for the 
requested 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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976.  
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid abuse therapy with methadone provided from 
October 4, 2021, to October 25, 2021. 
 
You asked the Plan to pay for opioid abuse therapy with methadone. 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 opioid abuse therapy with methadone provided from 
October 4, 2021, to October 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF services for the enrollee. 
The Plan denied your request. The Plan says rules for SNF care have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is far from baseline status and is unsafe 
to discharge home. The Plan denied your request. The Plan says the denial of authorization for SNF care is 
correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee would like a second opinion. The 
Plan denied your request. The Plan says a network provider can care for the enrollee's medical problem. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan has agreed to pre-approve 1 visit with 
an out-of-network provider for a second opinion. We found no exception that would require the Plan to pre-
approve additional out-of-network services. Therefore, we decided that the Plan does not have to pre-approve 
surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81286 XU, 81413, 81414 XU, 81442, 
81161, 81479) provided December 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the services to be paid. The Plan 
denied your request. The Plan says medical records have not been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services (81286 XU, 81413, 
81414 XU, 81442, 81161, 81479) provided December 15, 2021. In this case the Plan requested medical records for review. These medical records were not supplied. Therefore, we decided that the Plan does not have to pay 
for the lab services (81286 XU, 81413, 81414 XU, 81442, 81161, 81479) provided December 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Laminectomy for implantation of neurostimulator 
electrodes, plate/paddle, epidural (63655) and Insertion or replacement of spinal neurostimulator pulse 
generator or receiver, direct or inductive coupling (63685) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that without this surgery the enrollee could end up 
back in the hospital. The Plan denied your request. The Plan says that your request is not medically necessary 
because records show the enrollee has not had surgical treatment or that the enrollee is not a surgical candidate.  
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. Detailed 
documentation is not evident regarding this request being utilized as a late/last resort in this clinical scenario. 
The documentation does not indicate that the enrollee is not a surgical candidate. There is also no indication 
she is not a candidate for psychological therapies or that she has had a psychological evaluation. 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 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 
(63655) and Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive 
coupling (63685) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulating device provided on March 15, 
2022.  
You asked the Plan to pay for the electrical stimulating device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee did not meet criteria for the item rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that tumor treatment field therapy is covered for 
newly diagnosed Glioblastoma Multiforme (GBM). 
 
We looked at the file and Medicare rules. Review of the file shows that this was not a newly diagnosed 
Glioblastoma. Based on this information, we decided that Medicare rules for coverage of the electrical 
stimulating device have not been met. Therefore, we decided that the Plan does not have to pay for the 
electrical stimulating device provided on March 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 20, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance 
transport was a medical necessity and should be covered. 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 $225 
copayment for each one-way ground ambulance trip.  
 
You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on February 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's goal is to improve independence with 
activities of daily living (ADLs) and functional mobility, so she is able to return home with intermittent 
assistance from her family. The treating physician also says the enrollee is very motivated to return to her prior 
level of function, and go home safely. The Plan denied your request. The Plan says based on Medicare 
guidelines, the Inpatient Rehabilitation Facility (IRF) services you and/or your provider are requesting do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has had a decline in function, but this is from deconditioning. Our 
physician reviewer also found that  the enrollee would benefit from therapy, but does not require the intensity 
of therapy services provided on acute inpatient rehabilitation. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get your strength back up before going 
back home, as all your kids are in a different state. The Plan denied your request. The Plan says based on 
Medicare guidelines, the Inpatient Rehabilitation Facility (IRF) services being requested do not meet the 
requirements for approval 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee would benefit from therapy, but he does not require the intensity of 
therapy services provided on acute inpatient rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device 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 unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. 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 the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 7, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 7, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on November 27, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services provided were not related to 
the enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on November 27, 2021.