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

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that the science supporting this treatment 
is far greater than many other procedures that you will provide coverage for. This procedure fills a treatment 
gap for those enrollees that do not receive adequate relief from traditional conservative methods and do not 
have instability to indicate that fusion is the appropriate treatment. It is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the procedure is unproven and not medically necessary procedures 
are not covered by Medicare due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental and has insufficient evidence of efficacy. An 
Intracept device does not meet accepted standards of medical 
practice. 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 thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous vertebral augmentation provided to the enrollee 
on June 1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the clinical submitted does not include the required documentation to support meeting all of the 
criteria required for Medicare coverage. 
 
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 pay for the services. 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 detailed documentation evident regarding how long the low back pain has lasted. 
Additionally, there are no diagnostic imaging studies provided to corroborate an osteoporotic fracture at L1. 
Detailed documentation is not evident regarding all other causes of pain have been ruled out. There are no 
diagnostic and limited objective clinical studies provided to confirm/rule out any instability, allergy, infection, 
neural impingement, myelopathy, neural deficit or fracture retropulsion/canal compromise. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for percutaneous vertebral augmentation provided to the enrollee on June 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 77062. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
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 a home ventilator. Our reviewer says 
that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found this 
enrollee was recently hospitalized with acute respiratory failure requiring intubation. There is a diagnosis of 
chronic obstructive pulmonary disease (COPD), but there are no pulmonary function tests to confirm or assess 
severity. The enrollee also had acute pulmonary edema. Arterial blood gas (ABG) test showed mild CO2 retention. There is no documentation of chronic CO2 retention with ABG done while stable. If the enrollee 
does have chronic CO2 retention, she may benefit from BiPAP with AVAPS during sleep as an outpatient. 
Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services on July 14, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 $150 
copayment for ambulance services.  
 
You have been asked to pay a $150 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
on July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the foot arch supports (L3040, L3060) 
purchased on June 29, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from a provider who is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to issue reimbursement for the foot arch supports 
(L3040, L3060) purchased on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the billing provider is in-network 
and the service was medically necessary. The Plan denied your request. The Plan says the member must receive 
care from a network provider or it will not be covered except for urgent/emergency care, approval to see an 
out-of-network doctor, or kidney dialysis services from a Medicare-certified dialysis facility outside the Plans 
service area. In this case, prior authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 17, 2022. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says the member 
was in hospice on this date of service, therefore Traditional Medicare is the payer. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on July 21, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the charges were 
billed with a medical diagnosis of Age-related nuclear cataract, bilateral. Per the 2022 Evidence of Coverage, 
Chapter 4, page 95-97, it states eye refractions are only covered by your Plan if performed by a participating  
provider and performed as a routine screening. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Medicare does not pay for 
procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we 
decided that the Plan does not have to pay for an eye refraction provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided to the enrollee on 
August 26, 2022. 
 
You asked the Plan to pay for the visit. You say that you did not have any input in choosing your provider. The 
Plan denied your request. The Plan says there was no authorization, and the services were not urgent or 
emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 pay for the visit. Our reviewer says that the services 
at issue in this case were not medically reasonable or necessary. Our physician reviewer found that in this case, 
the record indicates that the enrollee was an in-patient at an assisted living facility and had a routine follow up 
psychiatric provider appointment. The record provided does not document that the visit was either emergent or urgent, but rather a routine follow-up. A routine follow-up appointment is a foreseeable visit. 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 visit have not been met. Therefore, we decided that the Plan does not have 
to pay for a domiciliary or rest home visit provided to the enrollee on August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the power wheelchair. You say that please consider reversing the denial 
decision for this enrollee's request for a customized wheelchair. Additional clinical information is attached to 
prove medical necessity. The Plan denied your request. The Plan says the Medicare DME benefit does not 
cover DME in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the power wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve the Group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit on August 5, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for an urgent care visit.  
 
You have been asked to pay a $10 copayment for an urgent care visit. This item/service falls within the 
Urgently needed services  benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent 
care visit on August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 27, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 00790, 99100 and 99140 billed for date of 
service November 11, 2021. 
 
You asked the Plan to pay for procedure codes 00790, 99100 and 99140. You say that the services at issue 
were billed correctly for payment. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 00790 is: Anesthesia for intraperitoneal procedures in 
upper abdomen including laparoscopy; not otherwise specified. 
 
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 code 00790. Our reviewer says that procedure 
code 00790 does not meet criteria for payment. Our reviewer found that the available medical record includes a 
one-page anesthesia record, with no anesthesia start and stop time, as well as documenting "bowel 
resection." In this case, there is insufficient documentation to confirm service provided, as well as units billed. 
 
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 code 00790 have not been met. We find that procedure codes 99100 
and 99140 have a status indicator of B on the Physician Fee Schedule. This means that procedure codes 99100 
and 99140 are not separately payable. Based on this information, we decided that Medicare rules for coverage 
of codes 99100 and 99140 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 00790, 99100 and 99140 billed for date of service November 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fusion T10 to pelvis with laminectomy (22610, 63046, 
20936). 
 
You asked the Plan to pre-approve Fusion T10 to pelvis with laminectomy. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 Fusion T10 to pelvis with laminectomy. 
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 justification for long fusion surgery T10-pelvis. There is no 
instability or deformity present. You have compression fractures without instability. Laminectomy alone may 
be appropriate but not long fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fusion T10 to pelvis with laminectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Fusion T10 to pelvis with laminectomy (22610, 63046, 
20936).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara airway clearance system (E1399). 
 
You asked the Plan to pre-approve the Volara airway clearance system. You say that this device is 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 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 Volara airway clearance system. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is inadequate evidence that this system provides airway clearance 
comparable with other approaches, or that it is effective in the treatment of Chronic Obstructive Pulmonary 
Disorder. The patient does not have cystic fibrosis, bronchiectasis, or neuromuscular disease. 
 
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 Volara airway clearance system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Volara airway clearance system (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance and supervision. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance 
and supervision. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
in this case, the record indicates that the enrollee has diabetes and Wagner 3 foot ulcer that had had significant 
improvement with standard wound care. The record does not indicate that the enrollee has failed an adequate 
course of standard wound therapy. The elements of the coverage criteria are not satisfied. The requested service 
is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance and supervision have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) 
and physician attendance and supervision (99183).