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

 
We decided that the Plan does not have to pre-approve surgical placement of interspinous process stabilization 
device (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that you hope for a favorable 
outcome to approve this preauthorization request and provide the necessary coverage that the enrollee should 
be entitled to. The Plan denied your request. The Plan says this procedure is experimental and investigational. 
There are not enough studies to show that the use of the interspinous process stabilization device will help in 
the enrollee's care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgical placement of interspinous process stabilization device (22869, 22870).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study and ultrasound provided on November 
15, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic services. You say that the enrollee resides in a nursing home. You 
say that the provider in this case has an exclusive contract with the nursing home where the enrollee resides. 
You also say that the services should be covered. The Plan denied your request. The Plan says the provider in 
this case is out of network. The Plan also says prior authorization was required but not obtained. 
 
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 provider in this case is not a network provider with the Plan. 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 extremity study and ultrasound provided on November 15, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for nutrition counseling provided on March 14, 2022. 
 
You asked the Plan to pay for nutrition counseling. You say that this service is clearly covered and other visits 
with this provider have been paid. The Plan denied your request. The Plan says that the denial of payment for 
this service is correct, because the Pick Your Perks benefit limit for 2022 has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The Plan contract says that the Plan covers reimbursement of up to $1,500 for extra benefits 
including nutritional counseling. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Your contract with the Plan covers nutritional counseling up to a combined 
benefit of $1,500 for 2022. You say that this service is covered and should be paid. The Plan says that the 
benefit limit for 2022 has been reached, so no further payment can be made. However, the Plan did not submit 
any documentation showing the amounts paid toward your 2022 Pick Your Perks reimbursement benefit. 
Without this information, we cannot determine whether your benefits were exhausted at the time this claim was 
processed. Therefore, the Plan has not shown that its decision to deny payment for this service is correct or 
justified according to your contract with the Plan. Therefore, we decided that the Plan has to pay for nutrition 
counseling provided on March 14, 2022.  
 
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 a pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON pneumatic compression device. You say that your leg has swelling 
and that the item is medically necessary. The Plan denied your request. The Plan says there are network 
providers within a reasonable distance of the enrollee's home who are able to provide the item needed. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device to be provided by an out-of-network (OON) provider.
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 services requested are medically necessary. The 
Plan denied your request. The Plan says the request 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 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a left hip fracture. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram services (93010-76) provided on June 
16, 2021. 
 
You asked the Plan to pay for the electrocardiogram services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says without a physician's 
interpretation, note, and signature, computer-generated ECG reports do not meet the requirements for the 
professional component of an ECG. 
 
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 93010 is routine electrocardiogram (ECG) using at least 
12 leads with interpretation and report only. 
 
We asked our coder 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 electrocardiogram services. Our reviewer says that the 
documentation does not support payment for the services billed. Our reviewer found Medicare criteria indicates 
that "Typically, when the ECG stress test is scheduled in advance, a separate ECG on the same day is not reasonable and necessary. An ECG is not a covered benefit when used for screening purposes or as part of a 
routine physical examination." In this case, the provider did not provide documentation to support need for 2 
routine ECG performed on same date of service. 
 
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 electrocardiogram services have not been met. Therefore, we decided that 
the Plan does not have to pay for the electrocardiogram services (93010-76) provided on June 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (22325, 22842) provided on September 13, 
2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
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 22325 is "Open treatment and/or reduction of vertebral 
fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar". 
 
We asked our coder 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 code 22325 is 
not supported by the records provided. Our reviewer found that the operative report describes open treatment of 
thoracic spine fracture. CPT 22325 would be coded for lumbar, and therefore this procedure code cannot be 
verified. 
 
We have also confirmed that code 22842 is an add-on code and has not been billed with a payable primary 
procedure code. Based on the claim submitted, Medicare billing criteria have not been met. 
 
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 (22325, 22842) provided on September 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain without 
contrast (70450) provided on January 19, 2022. 
 
You asked the Plan to pay for the CT of the head or brain. You say that this service was billed appropriately. 
The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 computed tomography (CT) of the head or brain without contrast 
(70450) provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement (11720), trimming of dystrophic nails 
(G0127), trimming of skin lesions (11056), and the domiciliary or rest home visit for the evaluation and 
management of a new patient (99324) rendered by the out-of-network (OON) provider on February 2, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the nail debridement (11720), trimming of dystrophic nails (G0127), trimming of 
skin lesions (11056), and the domiciliary or rest home visit for the evaluation and management of a new patient 
(99324) rendered by the out-of-network (OON) provider on February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a deep brain Stimulator. 
 
You asked the Plan to pre-approve a deep brain Stimulator. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that DBS is only covered for enrollees with 
Parkinsons Disease under certain conditions. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee has Parkinsons 
Disease. Based on this information, we decided that Medicare rules for coverage of a deep brain Stimulator 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a deep brain Stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on October 10, 2021. 
 
You asked the Plan to pay for the CT of the head or brain. You say that the enrollee had multiple exams on the 
date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 computed tomography (CT) of the head or brain (70450) 
provided on October 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on February 24, 2022. 
 
You asked the Plan to pay for the CT of the head or brain. You say that the enrollee had multiple exams on the 
date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 computed tomography (CT) of the head or brain (70450) 
provided on February 24, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that changing therapy to Evenity is the best course of 
action and will improve the enrollee's bone density. The Plan denied your request. The Plan says that the 
records do not show that the enrollee has tried or is unable to take biphosphonate drugs given by mouth or vein. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of age-related osteoporosis at high risk of fracture.  The record indicates that the enrollee has 
worsened T scores by Dexa scan while being treated with Prolia and Forteo. The record indicates that the 
enrollee has failed other therapy for osteoporosis. The Food and Drug Administration has stated that the 
requested drug is indicated for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have been met. Therefore, we decided that the Plan has to pre-approve 
Evenity.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic Profiling test (F1 Heme) (CPT code 
81455) provided on December 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact 
therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The rules say CPT Code 
81445 Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis 
when performed, 5-50 genes (EG, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, 
PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number 
variants or rearrangements, if performed is considered not medically necessary except when used to guide 
treatment decision making in individuals with non-small cell lung cancer.   
Therefore, we decided that the Plan does not have to pay for comprehensive genomic Profiling test (F1 Heme) 
(CPT code 81455) provided on December 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the request for Vertiflex Superion interspinous 
device at L4-5 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of Vertiflex Superion device (22869, 
22870, 77002). 
 
You asked the Plan to pre-approve Vertiflex Superion device. You say that you hope for a favorable outcome 
to approve this preauthorization request and provide the necessary coverage that the enrollee should be entitled 
to. The Plan denied your request. The Plan says this procedure is experimental and investigational. There is not 
enough studies to show that this device will help in the enrollee's care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve surgical placement of Vertiflex Superion device (22869, 22870, 77002).