Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on June 17, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). The Plan denied your request. The Plan says CPT code 
01930 has been overturned and CPT code 99100 remains denied as bundled services are not eligible for 
separate reimbursement. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on June 17, 2021.
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 the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and 
effective as the gold standard of decompression. 
 
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 the enrollee indicates that the enrollee has  chronic low back pain and lumbar spinal stenosis with 
neurogenic claudication. The record indicates that the enrollee has multi level multi-factorial disease and is 
indicated for decompressive surgery. The elements of the coverage criteria are not satisfied. 
 
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 Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant. 
 
You asked the Plan to pre-approve cochlear implant. You say that the enrollee's hearing performance falls 
below the 40% or less word recognition criteria for cochlear implant, and the enrollee has been approved as a 
cochlear implant candidate. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because it is unclear if there is limited benefit from appropriate hearing aids and a computed 
tomography (CT) scan was ordered but the results not provided. 
 
The Plan follows Medicare rules. Medicare rules state that cochlear implantation may be covered if certain 
criteria are met.  
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 cochlear implant. Our reviewer says 
that the enrollee does not meet the Medicare criteria for a cochlear implant. Our physician reviewer found the 
clinical notes did not clearly mention whether hearing aids were providing limited benefit to the enrollee. 
Secondly, while the physical examination showed no evidence of middle ear infection, no imaging 
documentation was provided attesting to suitable inner ear, auditory nerve, and central nervous system 
anatomy. An order for a temporal bone computed tomography (CT) scan was provided, but not the results of a 
scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cochlear implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cochlear implant.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator (64555). 
 
You asked the Plan to pre-approve the peripheral nerve stimulator. You say that the nerve stimulator is 
medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is non-
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 peripheral nerve stimulator. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested procedure is considered experimental for knee pain and is non-
covered. 
 
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 peripheral nerve stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a peripheral nerve stimulator (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC) (K0861) and accessories. 
 
You asked the Plan to pre-approve a PWC and accessories. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there is no home assessment available to ensure that yours home 
provides adequate access for this device. 
 
The Plan follows Medicare rules. Medicare rules say that the beneficiarys home must provide adequate access 
between rooms, maneuvering space, and surfaces for the operation of the POV that is provided. 
 
The file shows that there is no home assessment available to ensure that yours home provides adequate access 
for this device. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair (PWC) (K0861) and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on April 5, 2021. 
 
You asked the Plan to pay for the testing services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the validity of the claim 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 code. The file shows that the enrollee received Guardant360 testing. We looked at the file and the rules. The claim 
lists a place of service as an independent laboratory. If an independent lab bills for services, the place where the 
sample was taken is reported as the place of service. The records do not indicate that the specimen was 
obtained at the independent laboratory. Based on this information, we decided that Medicare rules for coverage 
of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing services provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on June 5, 2021. 
 
You asked the Plan to pay for the services provided. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code 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 code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab testing provided on June 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric hospital. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says if there has not yet been discharge from the hospital, partial hospitalization may be 
approved. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 admission.  Our reviewer says that the requested services are not medically reasonable or necessary. Our physician 
reviewer found based on a review of the records provided, it is not expected that you would improve in a 
reasonable period of time, beyond the dates in question, as you were not showing any dangerousness to self or 
others. There are auditory, but no visual hallucinations, and no aggressive behaviors. You were compliant and 
cooperative with treatment. It did not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he 
did not have any suicidal or homicidal thoughts. The health plans denial of continued inpatient psychiatric 
services appears appropriate. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient psychiatric hospital.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra Dro. 
 
You asked the Plan to pre-approve Xiidra Dro. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Xiidra Dro is not covered under the enrollee's 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 Xiidra Dro.  
 
Benefits for Xiidra Dro 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70553) provided August 9, 2021. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says only one unit of this service is supported. The claim is a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 70553 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 70553. Based on this information, we decided that Medicare rules for coverage of 
the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for 
radiology services (70553) provided August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography guidance for placement of radiation 
therapy fields (procedure code 77014) provided to the enrollee from April 12, 2021, to April 15, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the denial of the CT guidance for placement of radiation therapy fields was appropriate. 
 
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 77014 is "Computed tomography guidance for placement 
of radiation therapy fields." 
 We find that CPT code 77014 is not supported in the medical record. Specifically, it is not appropriate to 
separately report this code. 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 computed tomography 
guidance for placement of radiation therapy fields (procedure code 77014) provided to the enrollee from April 
12, 2021, to April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle diabetic test strips. 
 You asked the Plan to pre-approve the Freestyle diabetic test strips. You say that the Freestyle test strips are 
medically necessary. The Plan denied your request. The Plan says the requested brand of test strips is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. No medical records were provided to show that the plan preferred 
test strips would not meet the enrollee's needs. Based on this information, we decided that Medicare rules for 
coverage of the Freestyle diabetic test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Freestyle diabetic test strips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that you are requesting the off-label use of Imfinzi. The 
Plan denied your request. The Plan says Imfinzi is not FDA approved or compendia supported for the treatment 
of recurrent cholangiocarcinoma. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Imfinzi. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found that the FDA has not stated that the requested drug is indicated for the enrollee's 
condition and the Medicare approved cancer drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevator (E2300). 
 
You asked the Plan to pre-approve a power seat elevator. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevator (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on September 30, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says telehealth services must be provided by an in-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says if you choose to get one of these services by telehealth, you must use a network provider 
 
The requested provider in this case is not a network provider with the Plan. The Plan does not cover telehealth 
services when they are rendered by an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for the telehealth services provided on September 30, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided June 29, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed 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. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the place of service on the 
claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided June 29, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (U0005) provided on May 2, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services (U0005). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says authorization was not obtained 
prior to the services taking place. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says the Point of Service (POS) option lets you use doctors and hospitals outside the plan provider 
network. You will need to obtain authorization from the plan prior to seeking care. 
 
The requested 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. You are responsible for the $25 charge for code U0005. Therefore, we decided that the Plan does not have to 
pay for the laboratory services (U0005) provided on May 2, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure 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 there is little evidence in the medical literature to suggest that this 
is an appropriate procedure for the enrollee's back pain. 
 
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. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested procedure in the enrollee's 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 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 Intracept procedure for the enrollee.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an endoscopy provided on July 20, 2021. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that the endoscopy should be covered. 
You also say the hospital kept you until the next day and you never left the hospital. The Plan denied your 
request. The Plan says that you have been charged the correct cost sharing amount. 
 
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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit medical records. There is no evidence showing the 
endoscopy was not part of the emergency care needed to stabilize an emergency medical condition 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $50 copayment for emergency room visit. Your contract 
also says that emergency care includes services needed to evaluate or stabilize an emergency medical 
condition.  
 
The Plan says you must pay another $50 copayment for an endoscopy, in addition to the emergency room 
copayment. Based on the Plan contract, however, you cannot be asked to pay more than one $50 copayment for 
an emergency room visit for care needed to stabilize an emergency situation. Therefore, the endoscopy is not 
subject to a separate copayment. We decided that the Plan has to waive the copayment for an endoscopy 
provided on July 20, 2021.  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.