Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alignable system (L5910) and an addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968).

You asked the Plan to pre-approve a prosthetic replacement. You say that the enrollee is a bilateral amputee who was recently seen by his doctor to express concern that his left prosthetic was not properly fitting, loose and he has a concern that he may fall. He indicated that he does not feel "safe" in his old prosthesis due to excessive movement and felt it did not give him a secure fit, which requires him to use a cane for stability. The Plan denied your request. The Plan says the enrollee's current prosthesis was approved 12/2020, including an alignable system. Notes do not show that it is damaged beyond repair and cannot be re-used for approved socket. The enrollee's current foot is already paired with a multiaxial ankle; entire foot (and therefore both components) is still under warranty. Replacement for foot and replacement for ankle cannot be 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 a prosthetic replacement. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a K2 foot that is still under warranty and the requested foot is K2. The request of new prostheses exceeds the enrollee's functional need and does not meet the Medicare criteria of reasonable and necessary. The alignable system exceeds the enrollee's medical needs and does not meet the Medicare criteria of reasonable and necessary. He currently has an alignable system that was approved in 2020 and there is no evidence of damage beyond repair. His current system cannot be used for the approved socket.

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 prosthetic replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve an alignable system (L5910) and an addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening 
feature (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor 
control feature, swing and stance phase, includes electronic sensor (L5856). 
 
You asked the Plan to pre-approve a prosthetic leg with an electronic knee and an advanced foot and ankle. 
You say that you disagree with the denial. The Plan denied your request. The Plan says the request for a K3 
microprocessor knee exceeds your need and cannot be 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 a prosthetic leg with an electronic knee 
and an advanced foot and ankle. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found a level 3 ambulator has the 
ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the 
ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that 
demands prosthetic utilization beyond simple locomotion. In this case, you are a K3-level ambulator. The 
health plan has authorized a K3 level foot/ankle system. There is no documentation to support that you require 
a microprocessor knee over the mechanical knee that has been authorized. The requested component is not 
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 a prosthetic leg with an electronic knee and an advanced foot and ankle have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an addition, endoskeletal knee-
shin system, single axis, fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin 
system, stance flexion feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance 
extension, dampening feature (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor (L5856).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the coverage criteria 
has not been met. 
 
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 that the documents do not support the medical necessity for admission to an IRF due 
to lack of medical complexity and lack of nursing needs. While you would benefit from physical and 
occupational therapy, your rehabilitation needs can be safely provided in an alternate and low intensity setting such as 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
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 necessary. The Plan denied your request. The Plan says the use of interspinous process or interlaminar stabilization/distraction spacers is considered investigational.

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 requested Vertiflex superion interspinous device at L4-5, in this case, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on March 4, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this is a payable transport and has nothing to do with any other services on this date. The Plan denied your 
request. The Plan says the enrollee's claims history indicates they were in an inpatient hospital status on this 
date of service. The Plan also says that the referring claim shows type of bill 111 that shows an admit date of 
February 27, 2022, and discharge date of March 5, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by 
ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic 
services not available at the facility where the patient is an inpatient is included in the payment to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-emergency ambulance transportation and ground mileage have not been met. Therefore, 
we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (83789) provided on June 1, 2022.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does not have to pay for lab services (83789) provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable


We decided that the Plan does not have to pre-approve an Intracept procedure (64628).

You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and 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 Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy.

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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met.

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 that the documentation does not support the medical necessity for admission to an IRF due to lack of medical complexity and lack of nursing needs. While the enrollee would benefit from physical and occupational therapy the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME) under your special 
supplemental benefits for chronically ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you feel the services are medically 
necessary/ The Plan denied your request. The Plan says the provider did not respond to requests to submit an 
attestation form to verify the qualifying chronic condition(s) required for coverage of the SSBCI benefit you 
requested. Without confirmation from a provider regarding your condition(s), your SSBCI benefit cannot be 
approved. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits for DME have not been met.  Specifically, we have confirmed that the record does not indicate that you have one of the eligible conditions 
listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve durable 
medical equipment (DME) under your special supplemental benefits for chronically ill (SSBCI).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 19, 
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 July 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on May 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says as a member of our plan, the enrollee must use network providers. If 
the enrollee receives unauthorized care from an out-of-network provider, we may deny coverage and the 
enrollee will be responsible for the entire cost. 
 
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 skilled nursing facility care provided on May 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on June 25, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the anesthesia services. You say that you should not be held responsible for not 
obtaining a prior authorization because it is the facilities responsibility. The Plan denied your request. The Plan 
says the out-of-network services were not authorized. 
 
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 anesthesia services provided on June 25, 2021, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support the need 
for the Intracept procedure. The Plan denied your request. The Plan says the clinical value and effectiveness of 
the Intracept procedure in the setting of lumbar spondylosis have not been demonstrated in the peer-reviewed 
literature. The Plan says that more research is needed to show safety and efficacy of the procedure. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care from October 5, 2022, to the present.

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 that the enrollee does not have any documented daily skilled nursing or skilled therapy needs.

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 from October 5, 2022, to the present.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you would like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says The member is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital (LTACH).

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that the enrollee requires services that she is not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on February 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says as a member of our plan, the enrollee must use network providers. If the 
enrollee receives unauthorized care from an out-of-network provider, we may deny coverage and the enrollee 
will be responsible for the entire cost. 
 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 inpatient hospital stay provided on February 21, 
2022, by an out-of-network (OON) provider.