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

 
We decided that the Plan does not have to pre-approve a CT scan of the lumbar spine (72131). 
 
You asked the Plan to pre-approve a CT scan of the lumbar spine. You say that the requested CT scan of the 
lumbar spine is medically necessary. The Plan denied your request. The Plan says the requested CT scan of the 
lumbar spine does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 to pre-approve a CT scan of the lumbar spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you are noted to have a 
history of chronic back pain. It is otherwise unclear from the notes provided for review as to how a repeat CT 
scan at this interval would be reasonable and necessary for your ongoing evaluation and treatment. You have 
otherwise been approved for MRI of the same anatomical region. The MRI would be expected to provide more 
detailed findings on your anatomy for their current case of care. There is not a clear indication at this time that 
there are any immediate plans for surgical intervention either. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the lumbar spine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT scan of the lumbar spine (72131).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says claims for ventilators used to provide continuous positive airway pressure (CPAP) 
or bi-level CPAP therapy for non-covered conditions will be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee has severe chronic obstructive pulmonary disease (COPD) and chronic hypercarbic respiratory failure 
with frequent acute exacerbations.  The patient has been prescribed bilateral positive airway pressure (BiPAP) and a home ventilator in the past, 
but has reportedly been non-compliant, although the records do not contain any compliance downloads. There 
are results from an arterial blood gas (ABG) study provided, but a venous blood gas (VBG) and the history 
leave little doubt of chronic C02 retention. Medicare does not cover a home ventilator when used as bipap, and 
the AVAPS mode can be provided via bilateral positive airway pressure (BiPAP). If the patient is unable or 
unwilling to use BiPAP, it is not likely the patient will use a ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services billed with procedure codes 95923, 95921 and 
95922 for date of service November 29, 2021. 
 
You asked the Plan to pay for procedure codes 95923, 95921 and 95922. You say that these services were 
necessary and were billed appropriately. The Plan denied your request. The Plan says the provided 
documentation does not support these services as billed. 
 
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 95923 is testing autonomic nervous system function; 
sudomotor, including 1 or more of the following quantitative sudomotor axon reflex test (SQART), silastic 
sweat imprint, thermoregulatory sweat test; and changes in sympathetic skin potential. The CPT Code Manual 
definition of code 95921 is testing autonomic nervous system function; cardiovagal innervation 
(parasympathetic function), including or more of the following heart rate response in deep breathing with 
recorded R-R interval, Valsalva ratio, and 30-15 ratio and the CPT Code Manual definition of code 95922 is 
testing autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at 
least 5 minutes of passive tilt. 
 
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 procedure codes 95923, 95921 and 95922. Our reviewer says 
that these services are not supported as reported. Our reviewer found that the procedure report notes that, 
autonomic nervous system test performed to test parasympathetic function. A quantitative sudomotor test 
was performed; bilateral upper and lower vascular tests were performed to test the integrity of the vascular 
system. In this case, the description of the procedures at issue are not documented, and therefore these services 
cannot be verified as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95923, 95921 and 95922 have not been met. Therefore, we 
decided that the Plan does not have to pay for services billed with procedure codes 95923, 95921 and 95922 for 
date of service November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve an endosteal implant. You say that these implants are required. The Plan 
denied your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
endosteal implant (D6010) provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit provided on January 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) electronic connection 
between wheelchair controller and two or more power seating system motors (E2311) harness for upgrade to 
expandable controller (E2313) specialty joystick handle for hand control interface, prefabricated (E2323). 
 
You asked the Plan to pre-approve the upgraded electronic. You say that please review for appeal. Evaluation 
was completed by physical therapy on 10/19/21 and the documents are attached. Please review correctly. The 
Plan denied your request. The Plan says E2377, E2311, E2313, and E2323 exceed the enrollee's needs and are 
not reasonable and necessary. 
 
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 upgraded electronic. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the enrollee has a neurologic disorder with functional deficits. Criteria 
for a power wheelchair are met. The requested electrical accessories are not medically necessary as the enrollee 
does have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. 
 
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 upgraded electronic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) electronic connection between wheelchair 
controller and two or more power seating system motors (E2311) harness for upgrade to expandable controller 
(E2313) specialty joystick handle for hand control interface, prefabricated (E2323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PNT using a Sprint device. 
 
You asked the Plan to pre-approve PNT using a Sprint device. You say that PNT using a Sprint device is 
medically necessary. The Plan denied your request. The Plan says PNT using a Sprint device does not meet the 
Medicare coverage criteria. 
 
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 PNT using a Sprint device. Our 
reviewer says that PNT using a Sprint device is not considered medically reasonable and necessary. Our 
physician reviewer found this is considered experimental/ investigational for a trial of PNS for low back pain.  
Therefore, the request is considered 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 PNT using a Sprint device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve PNT using a Sprint device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on March 21, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you were told to go to the ER so it 
should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $110 
copayment for each covered emergency room visit.  
 
You have been asked to pay $110 copayment for ER visit. ER visits fall 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 ER visit provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that you do not want to change to another 
psychiatrist since you trust your current provider. The Plan denied your request. The Plan says no prior 
authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
psychotherapy. We found no exception that would require the Plan to pay for the psychotherapy. Therefore, we 
decided that the Plan does not have to pay for the psychotherapy provided on March 9, 2022, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the enrollee had multiple exams on this date 
of service and attached reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551.  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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service March 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that records do not show inpatient level of care is 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee's history 
was significant for tobacco use, hypertension, and hyperlipidemia; however, recent notes do not suggest an 
unstable condition or high risk clinical situation that might suggest the patient requiring hospital services that 
would likely cross 2 midnights following the planned surgery. The records also did not show that the planned 
procedure was going to be an anterior and posterior approach. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reverse shoulder replacement surgery. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this procedure is 
not medically necessary. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of rotator cuff pathology and no recent physical therapy for 
shoulder pain. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve reverse shoulder replacement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $201.60 coinsurance for catheters received on January 24, 
2022. 
 
You asked the Plan to waive the $201.60 coinsurance for catheters. You say that in the past, you have not had 
to pay for catheters. The Plan denied your request. The Plan says the cost share has been applied 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 20% 
coinsurance for Durable Medical Equipment and Related Supplies.  
 
You have been asked to pay a $201.60 coinsurance for catheters. Catheters fall within the Durable Medical 
Equipment and Related Supplies benefit category. The Plans allowance was $1008; $1008 x 20% = $201.60. 
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 $201.60 coinsurance for catheters received on January 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that SCS implantation is covered when specific 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has longstanding chronic low 
back pain from post-laminectomy syndrome. He has had physical therapy, a home exercise program, and 
activity modification. He also had epidural steroid injections. He has psychological clearance for the SCS trial. 
He has failed appropriate conservative care and meets the Medicare criteria for coverage of the SCS trial. The 
services are therefore reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a spinal cord stimulator (SCS).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pacemaker services provided on March 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the pacemaker services. You say that you were not aware that your pacemaker 
services were not approved. The Plan denied your request. The Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
pacemaker services. We found no exception that would require the Plan to pay for the pacemaker services. 
Therefore, we decided that the Plan does not have to pay for the pacemaker services provided on March 17, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orthovisc. Our reviewer says that 
Orthovisc is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found 
that there is no indication that the patient has tried and failed the required drug(s) and two intra-articular 
corticosteroid injections. There is no indication that the Plan's required drug(s) and a second intra-articular 
corticosteroid injection would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.