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

 
We decided that the Plan does not have to pre-approve hypoglossal nerve stimulator. 
 
You asked the Plan to pre-approve hypoglossal nerve stimulator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that hypoglossal nerve stimulators are only covered for 
certain indications. 
 
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 hypoglossal nerve stimulator. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found you sleep apnea. The documentation does not indicate a failure of, or 
intolerance of continuous positive airway pressure (CPAP).  The elements of the coverage criteria are not 
satisfied. Therefore, you do not meet criteria for the requested 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 hypoglossal nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hypoglossal nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein. 
 
You asked the Plan to pre-approve endovenous ablation therapy of incompetent vein. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous ablation therapy is only covered for 
certain indications. 
 
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 endovenous ablation therapy of 
incompetent vein. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found the documentation shows that the enrollee 
has had success with using compression stockings and that the veins do not bother the enrollee. There is ample 
documentation in the medical record that the enrollee is not having significant symptoms and that the enrollee 
is doing well with the compression stockings. It is not possible to support the appropriateness/medical necessity 
of the treatments in question in the absence of significant symptoms and without an assessment of arterial 
perfusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy of incompetent vein have not been met. Therefore, 
we decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 10, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are disputing the share 
cost. 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 $325 
copayment for outpatient hospital services.  
 
You have been asked to pay $325 copayment for outpatient surgery. This item/service falls within the 
outpatient hospital 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 outpatient 
surgery provided on August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Inheritable Cardiovascular Panel (81479, 
81439, 81411, 81410, 81286) provided on March 12, 2021. 
 
You asked the Plan to pay for the Comprehensive Inheritable Cardiovascular Panel. You say that this claim 
should be covered. The Plan denied your request. The Plan says screening asymptomatic patients for 
cardiovascular risk is statutorily excluded by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Comprehensive Inheritable Cardiovascular Panel, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the Comprehensive Inheritable Cardiovascular Panel (81479, 81439, 81411, 
81410, 81286) provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99223 billed for date of service August 11, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the services at issue have been billed 
correctly. 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. 
 
We find that payment for procedure code 99223 is not supported in the case record. Specifically, code 99223 is 
not a recognized code when submitted on an outpatient hospital Part B bill type (12x and 13x). In this case, the 
procedure code at issue was submitted on an outpatient hospital bill type 131. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99223 billed for date of service August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic test and a specialist office visit 
provided on November 10, 2021. 
 
You asked the Plan to waive the copayment for diagnostic test and a specialist office visit. You say that you 
disagree with the copayments. 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 $50 
copayment for in-network Outpatient diagnostic tests and a $35 copayment for in-network 
physician/practitioner services/specialist.  
 
You have been asked to pay a $50 copayment for diagnostic test and a $35 copayment for a specialist office 
visit. The total amount you are being asked to pay is $85 ($50 + $35 = $85). 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 diagnostic test and a specialist office visit provided on November 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 01, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollees network primary care physician (PCP) or plan must give the 
enrollee approval in advance before they can use providers not in the plan's network. This is called giving them 
a "referral." 
 
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 home health services provided on July 01, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on September 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you misunderstood your plan and thought it ran 
from August to August. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your $1,000 yearly dental benefit was exhausted on date of service August 11, 2022. Therefore, we 
decided that the Plan does not have to pay for a cleaning (D1110) provided on September 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says when the enrollee is 
ready to leave the hospital, they can safely receive care in another setting such as skilled nursing facility (SNF), 
at home with home health services or outpatient setting if appropriate. 
 
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 enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is is currently receiving 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visit provided on July 6, 2022. 
 
You asked the Plan to waive the coinsurance for office visit. You say that you are disputing the share cost. 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 20% 
coinsurance for physician/practitioner services, including doctor's office visits. The allowed amount of this 
office visit total $121.83, resulting in a coinsurance amount of $24.37. 
 
You have been asked to pay 20% coinsurance for office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 coinsurance for office visit provided on July 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injections (ESI) 
 
You asked the Plan to pre-approve an ESI. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using SAME scale* for at 
least three months. 
 
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 ESI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the duration of relief provided by the prior 
injection was not documented to be at least 50 percent for at least three months. 
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injections (ESI)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on September 29, 
2022 
 
You asked the Plan to waive the copayment for specialist visit. You say that you are disputing the share cost. 
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 $50 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $50 copayment for specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 specialist visit provided on September 29, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on July 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has greatly 
impacted their quality of life. The Plan denied your request. The Plan says unproven procedures are not 
covered by Medicare. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis of the lumbar spine with neurogenic 
claudication. Current evidence based medical guidelines and peer reviewed literature do not fully support the 
spinal decompression device procedure over the standard lumbar laminectomy. There is a lack of large volume, 
long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition. 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device (E0656, E0673). 
 
You asked the Plan to pay for intermittent limb compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for the prevention of deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
(E0656, E0673).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic pontic (D6245) for tooth #'s 12 and 13 
and a porcelain/ceramic retainer crown (D6740) for tooth #'s 11 and 14 provided on July 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that based on the information for your dental 
benefits and eligibility provided to your dentist, the claim should be approved. The Plan denied your request. 
The Plan says a porcelain/ceramic pontic (D6245) and a porcelain/ceramic retainer crown (D6740) are not 
covered dental services. 
 
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 pay for a 
porcelain/ceramic pontic (D6245) for tooth #'s 12 and 13 and a porcelain/ceramic retainer crown (D6740) for 
tooth #'s 11 and 14 provided on July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the closed-circuit television (CCTV), provided on June 27, 
2022. 
 
You asked the Plan to pay for the CCTV. You say that the item is medically necessary. The Plan denied your 
request. The Plan says Lasik keratotomy, LASIK surgery, and other low vision aids are not covered in any 
condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the closed-circuit television (CCTV), provided on June 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not need daily skilled services to be provided only on an inpatient 
basis in a SNF. Their needs can be met at an alternate level of care. 
 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 The enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72192 billed for date of service July 14, 
2022. 
 You asked the Plan to pay for procedure code 72192. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 72192 is bundled into 
payment for code 74176. 
 
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 72192 
is a column II code to column I code 74176. 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 72192 billed for date of service July 14, 2022.