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

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each 
additional 15 minutes (97811) and infrared therapy (97026) provided January 21, 2022. 
 
You asked the Plan to pay for the acupuncture and infrared therapy services. You say that please review all 
documentation included in this request and approve your services for payment as these services were medically necessary. The Plan denied your request. The Plan says the services was rendered by a non-covered provider 
type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, Medicare rules says that acupuncture treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. The 
services was rendered by a licensed acupuncturist, not a physician. This provider is not supervised by any 
physician, PA, or NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 
minutes (97810) acupuncture, each additional 15 minutes (97811) and infrared therapy (97026) provided 
January 21, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says that the enrollee has not tried and failed the preferred drugs, zoledronic acid 
or pamidronate. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the step 
therapy criteria have been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs. The reviewer also found that the enrollee's physician 
states that the plan's required drugs would likely be less effective for the enrollee in this case. Therefore, the 
reviewer found that the step therapy criteria have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia (J0897).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (99225, 99217) provided on December 13, 
2021 to December 14, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the observation care. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as there was no prior 
authorization 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 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 observation care (99225, 99217) provided on 
December 13, 2021, and December 14, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transesophageal echocardiography (TEE) provided on 
December 15, 2021. 
 You asked the Plan to pay for the TEE. The Plan denied your request. The Plan says it cannot be determined 
how the enrollee came to the servicing provider, or whether the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the transesophageal echocardiography. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there was insufficient detailed support made for approval. Therefore, the 
TEE will be considered 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 the transesophageal echocardiography have not been met. Therefore, we 
decided that the Plan does not have to pay for the transesophageal echocardiography (TEE) provided on 
December 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Impedimed L-dex testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has invasive ductal cell 
carcinoma of the right breast treated with a lumpectomy. She underwent bioimpedance spectroscopy on 
September 7, 2021. Impedimed L-dex testing is requested for quarterly surveillance of possible lymphedema. 
The evidence in the medical literature at this time is insufficient to support that bioimpedance spectroscopy is 
medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Impedimed L-dex testing.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on January 6, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that there is no enough information to consider the claim; 
however, the Plan has not provided a clear denial reason for the services. There is no documentation or 
explanation from the Plan to support that the services are not covered per Medicare rules. Therefore, we 
decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on January 6, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 November 22, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee was confined to his bed. You also say that the enrollee was combative and lethargic, and the 
ambulance was the safest form of transportation. The Plan denied your request. The Plan says these services are 
not covered. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that there is no documentation that the ambulance 
transport on November 22, 2021 met Medicare criteria for medically reasonable and necessary for the patient. 
Our physician reviewer found there is no documentation that other means of transport (such as stretcher van) 
were contraindicated for this patient. Our reviewer also found that there is no clear documentation that the 
patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance could provide for safe transport on November 22, 2021. 
 
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 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 November 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 27, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service February 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, flex foot system 
(L5980), a multi-axial rotation unit (L5986), an endoskeletal knee-shin system, polycentric, hydraulic swing 
phase control, mechanical stance phase lock (L5814), an endoskeletal, knee-shin system, stance flexion feature 
(L5845) and an endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested prosthetics are medically necessary. 
 The Plan denied your request. The Plan says the requested prosthetics do not meet criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare allows for replacement of a prosthesis or prosthetic component if there is a change in 
the physiological condition of the enrollee, there is irreparable wear of the device or a part of the device or if 
the condition of the device, or part of the device, requires repairs and the cost of such repairs would be more 
than 60% of the cost of a replacement device, or the part being replaced. In this case, the health plan has 
authorized a replacement prosthesis without the advanced knee and ankle-foot component.  The medical 
documentation from the provider does not support that the enrollee requires a K3 level knee and ankle-foot 
feature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an all-lower extremity prostheses, flex foot system (L5980), a multi-axial rotation unit 
(L5986), an endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance 
phase lock (L5814), an endoskeletal, knee-shin system, stance flexion feature (L5845) and an endoskeletal 
system, above knee or hip disarticulation, knee extension assist (L5850).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 12 PT visits. You say that the enrollee would benefit from increased manual 
therapy and long duration stretching to further improve functional motion and maintain gains from week to 
week. The Plan denied your request. The Plan says that the requested PT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 12 PT visits. Our reviewer says that 12 
PT visits are medically necessary. Our physician reviewer found the provided documentation states that you are 
still receiving medical treatment for spasticity, thus it would take a professional therapist for continued 
maintenance and treatment. Therefore, the reviewer found that 12 additional PT sessions are medically 
reasonable and 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 12 PT visits have been met. Therefore, we decided that the Plan has to pre-
approve 12 additional physical therapy (PT) visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertos mild procedure. 
 
You asked the Plan to pre-approve Vertos mild procedure. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vertos mild procedure. 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 longstanding lower back pain. The requested procedure is 
experimental. More research is needed. Therefore, the enrollee does 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 Vertos mild procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vertos mild procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chiropractic services (98941) provided from February 25, 
2022, to March 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they are 
excluded from the Plan's coverage. 
 
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 (98941) provided from 
February 25, 2022, to March 3, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ablation of malignant prostate tissue, transrectal, with 
high intensity-focused ultrasound (HIFU), including ultrasound guidance (55880). 
 You asked the Plan to pre-approve HIFU. You say that the requested service is medically necessary. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that whole gland high intensity-focused ultrasound 
(HIFU) is considered medically necessary as a local treatment for recurrent prostate cancer (PCa) following 
radiation therapy (RT) when ALL of the following criteria are met 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve HIFU. Our reviewer says that the 
coverage criteria for the requested HIFU has not been met. Our physician reviewer found the provided 
documentation does not clearly describe the enrollee as having had any treatment for the prostate cancer, 
including radiation treatment. The reviewer found that this is not a recurrence of disease. Therefore, the 
reviewer found that the criteria for the requested HIFU has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIFU have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), 
including ultrasound guidance (55880).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 81161 is not separately payable. 
 
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 81161 is a column II code to column I code 81413. 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 the laboratory services rendered on August 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a general health panel provided on February 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the general health panel. You say that the services should be covered as you 
disagree with the denial and are a participating provider. The Plan denied your request. The Plan says the 
services denied correctly as they were not emergent and 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 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 a general health panel provided on February 14, 
2022, by an out-of-network (OON) provider.