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

 
We decided that the Plan does not have to pre-approve routine transportation services. 
 
You asked the Plan to pre-approve routine transportation services. You say that this transportation is necessary. 
The Plan denied your request. The Plan says the Plan's contractual criteria for routine transportation have not 
been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the one-way trip mileage does not exceed 50 miles.  
 
We looked at your request, the records in the case file, and the rules. In this case, the record confirms the one-
way driving distance would exceed 50 miles. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve routine transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for infusions and injections provided on 
November 19, 2021. 
 
You asked the Plan to waive the cost share for infusions and injections. You say that you reached your out-of-
pocket maximum and this should be covered. The Plan denied your request. The Plan says the cost share 
applied is correct. The Plan says the cost share applied is correct because your out-of-pocket maximum was not 
met until this claim was processed. 
 
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 $395 
copayment for each Medicare-covered surgery or other services and 20% coinsurance for each Medicare-
covered Part B drug. 
 
You have been asked to pay a total of $1, 684.04. 
 
Date of Service Service Allowed Amount Cost Share Member Liability 
November 9, 2021 Infusion into vein $195.04 $395 $195.04 
November 9, 2021 Infusion into vein $115.02 $395 $115.02 
November 9, 2021 Infusion into vein $59.39 $395 $59.39 
November 9, 2021 Injection $22,416.03 20% coinsurance $1,314.59 Met 
OOP Max 
Total:    $1684.04 
 
Injections fall within the Medicare Part B Prescription Drugs benefit category and the infusions fall within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 cost share for infusions and 
injections provided on November 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that all your toes were removed from your right foot. 
You say that you believe you would benefit from more focused inpatient physical therapy to recover mobility.  
The Plan denied your request. The Plan says inpatient rehabilitation is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found you were admitted for osteomyelitis of the foot and had a trans-metatarsal 
amputation of the foot. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Minuteman G3R interspinous 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 medical studies have not proven that this device is helpful for treatment. 
 
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 that this device 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve implantation of the Minuteman G3R interspinous device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microsurgical techniques (69990) provided on January 15, 
2022. 
 
You asked the Plan to pay for microsurgical techniques (69990). The Plan denied your request. The Plan says 
Medicare rule for payment of this claim has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of microsurgical techniques (69990) 
provided on January 15, 2022. have been met. Specifically, medical records were not submitted to determine if 
coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for microsurgical 
techniques (69990) provided on January 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple venous procedures intravascular ultrasound 
followed by angioplasty and stenting with sedation. 
 
You asked the Plan to pre-approve multiple venous procedures intravascular ultrasound followed by 
angioplasty and stenting with sedation. 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 the plan of care, for a 90 day episode of care, is based 
on the treating physicians assessment. The minimum evaluation that must be documented includes the history, 
physical examination, CEAP clinical classification, VCSS, and a venous duplex scan documenting the venous 
flow. 
 
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 multiple venous procedures 
intravascular ultrasound followed by angioplasty and stenting with sedation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record provided is insufficient to establish the 
medical necessity of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. 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 multiple venous procedures intravascular ultrasound followed by angioplasty 
and stenting with sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and radiology services provided on January 
20, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory and radiology services. You say that authorization was obtained 
through the only insurance provided to the ordering physician office. The ordering physician office would have 
obtained authorization through the Plan if the correct insurance information was provided to the enrollee. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 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 the laboratory and radiology services provided on 
January 20, 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 a Freestyle Libre 2 Sensor Kit. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 Sensor Kit. You say that you are concerned about 
hypoglycemia and experience blood glucoses as low as 29 mg/dl. You say that you have been hospitalized in 
the past for hypoglycemia. You say that you do not trust the portable meter you currently use because it is old. 
The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 Sensor Kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Sensor Kit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood smear interpretation services (85060) provided on 
December 3 to December 7, 2021. 
 
You asked the Plan to pay for blood smear interpretation. You say that the services at issue were a medical 
necessity for the enrollee. 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 all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
We looked at the file and Medicare rules. Procedure code 85060 identifies the professional component of 
clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal 
smear for hospital inpatient. No payment is recognized for code 85060 furnished to hospital outpatients or non-
hospital patients. In this case, the services at issue were billed with place of service code 22, indicating services 
performed at an outpatient hospital. Based on this information, we decided that Medicare rules for coverage of 
blood smear interpretation have not been met. Therefore, we decided that the Plan does not have to pay for 
blood smear interpretation services (85060) provided on December 3 to December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 12, 2022, and 
February 23, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you were unaware the chiropractor was 
out-of-network. The Plan denied your request. The Plan says services were done by a provider not in the Plan's 
network and services are only covered when you receive care from an in-network provider. 
 
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 chiropractic services provided on January 12, 
2022, and February 23, 2022, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of lumbar spine 
without contrast (72148).  
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the MRI is medically necessary to 
get properly diagnosed so you can get the right treatment. The Plan denied your request. The Plan says there is 
no documentation that you have tried conservative treatment including physical therapy, topical medications, 
and medications such as ibuprofen if thought to be safe to take by your doctor for at least 4 weeks. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not medically reasonable and necessary. Our physician 
reviewer found there is no documentation of recent physical therapy for lower back pain. There are no red flags 
for MRI at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve magnetic resonance imaging (MRI) of lumbar spine without contrast 
(72148).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there have been no specific studies done to identify that the basivertebral nerve is the 
cause of 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stress transthoracic echocardiography. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation provided that would support the need for stress 
echocardiography. 
 
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 at issue in this case is the medical appropriateness and necessity of carrying out a stress 
echocardiogram for "preventive screening." You are diabetic and asymptomatic. Your pre-test probability for 
an abnormal test is low, and there is no documentation that the electrocardiogram shows an uninterpretable 
pattern. There is no evidence provided that would support the need for stress echocardiography. In summary, 
there is insufficient documentation to support the medical necessity for the requested stress echocardiography 
in your clinical management. 
 
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 stress transthoracic echocardiography.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on February 
23, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not payable 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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, payment for this code may 
only be made if the physician interprets an abnormal smear for the hospital inpatient. Review of the file shows 
that this code was billed with a place of service 22 (outpatient hospital), which is considered not an appropriate 
place of service for this code. This means this claim is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of the blood smear services have not been met. Therefore, we decided 
that the Plan does not have to pay for the blood smear services coded 85060 provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 6, 2021. 
 
You asked the Plan to pay for the office visit. You say that this claim should be reprocessed and paid because 
this service, by this provider, was previously paid in 2019 and 2020. The Plan denied your request. The Plan 
says the services provided to you by this provider were incorrectly paid as this provider is out of network and 
no authorization was found for any of these services. 
 
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 an office visit provided on December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa capsule. 
 
You asked the Plan to pre-approve Vascepa. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Vascepa capsule.  
 
Benefits for Vascepa 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosant; multiple incompetent veins 
(other than telangiectasia), same leg (CPT code 36471 x3). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the documentation does not support the absence of saphenous vein reflux. 
 
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 services. Our physician reviewer 
found the documentation does not support the medical necessity of the treatments in question. For treatment of 
tributary veins with sclerotherapy to be considered medically necessary, there would have to be documentation 
of ongoing significant symptoms despite continued conservative care at least 6 weeks after resolution of truncal 
reflux. Currently, documentation demonstrates untreated reflux and therefore sclerotherapy does not meet the 
criteria for coverage. 
 
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 pre-approve injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg 
(CPT code 36471 x3).