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

 
We decided that the Plan does not have to pay for vasopneumatic device (97016) subcutaneous and 
intramuscular injection (96372) unclassified drug (J3490) pyridoxine injection, 100 mg (J3415) vitamin B-12 
injection (J3420) thiamine injection (J3411) provided April 30, 2021 to May 27, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says these items are not covered benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. The clinical value and effectiveness of electrical cell stimulation and 
the subcutaneous injection of FDA Nutri-Pharmaceutical blend in the setting of chronic pain syndrome have 
not been demonstrated in the peer-reviewed literature. The clinical value and effective of utilizing 
vasopneumatic device therapy in the setting of chronic pain syndrome have not been demonstrated in the peer-
reviewed literature. Based on this information, we decided that Medicare rules for coverage of the outpatient 
services have not been met. Therefore, we decided that the Plan does not have to pay for vasopneumatic device 
(97016) subcutaneous and intramuscular injection (96372) unclassified drug (J3490) pyridoxine injection, 100 
mg (J3415) vitamin B-12 injection (J3420) thiamine injection (J3411) provided April 30, 2021 to May 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on September 21, 2020. 
 
You asked the Plan to pay for physical therapy services. You say that the medical records required to reprocess 
the claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the service 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on September 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saxenda. 
 
You asked the Plan to pre-approve Saxenda. The Plan denied your request. The Plan says this is not covered 
under the enrollee's Part B plan. 
 
 
 
 
 
 
 
 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 Saxenda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 15, 2021, to November 17, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says there is no evidence of blood infection, persistent low blood oxygen 
levels, need for a breathing machine, new onset confusion that did not improve for a period of time, infection 
caused by a serious virus, or a collection of pus outside of the lung. 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee has a history of dementia, schizophrenia, and chronic obstructive 
pulmonary disease (COPD), who was admitted to the hospital with fever and pneumonia. He initially had 
hypoxia prior to arrival to the emergency department (ED), but was treated  with IV antibiotics, oxygen and on 
admission only was on 2L or less oxygen support while alert, responding to treatment, hemodynamically 
stable, and tolerating PO. There was no report of failing outpatient treatment for this uncomplicated CAP. 
There was no indication from the documentation that the patient required hospital care that would likely cross 2 
midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from November 15, 2021, to 
November 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support, emergency transport (A0427) provided on November 2, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $240 
copayment for each separate Medicare-covered ambulance service.  
 
 
 You have been asked to pay a $240 copayment for the Medicare-covered ambulance service provided. 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 the ambulance service, advanced life support, emergency 
transport (A0427) provided on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided to the enrollee on September 9, 
2021. 
 
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 since both claims were billed to mobile x-ray the claim billed with the professional component 
should be denied, since both claims should not be paid for the same provider with same Tax ID number. 
 
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 71046 is "Radiologic examination, chest; 2 views." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the provider performed mobile x-ray 
services and performed the interpretation.  Therefore, this procedure would not be reported with a 
TC/PC modifier when billing both modifiers for the same procedure. 
 We looked at this coder'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 x-ray services provided to the enrollee on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 29, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 provider in this case is not a network provider with the Plan. 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 medical services provided on November 29, 2021, by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that Retacrit is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that 
Retacrit is not medically necessary. Our physician reviewer found the records do not document that the patient 
has a medically accepted indication for the Retacrit as defined by Medicare criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on January 3, 2022. 
 
You asked the Plan to pay for the shingles vaccine. You say that you were at a wellness visit and it was 
suggested you needed an updated shingles vaccine. You say that this is a preventive immunization, and you 
wouldn't know which shots would be paid for. The Plan denied your request. The Plan says the shingles 
vaccine is a part D drug which is not a covered benefit under this medical plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to this vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on January 3, 2022.  
 
Benefits for the shingles vaccine 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that 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 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of IV or oral bisphosphonates is required before alternatives can be considered. 
 
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 Prolia 
is not medically necessary. Our physician reviewer found based on the medical records provided the enrollee 
may have adverse effects with an oral bisphosphonate due to her gastroesophageal reflux disease but there is no 
indication that zoledronic acid would likely be less effective or have adverse effects for the patient. 
 
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 not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. You say that Xgeva is medically necessary. The Plan denied your 
request. The Plan says a trial of pamidronate or zoledronic acid is required before alternatives can be 
considered. 
 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 Xgeva. Our reviewer says that Xgeva is 
not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs, or 
any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gabapentin. 
 
You asked the Plan to pre-approve Gabapentin. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
 
 
 
 
 
 
 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 Gabapentin.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 14, 2021. 
 
You asked the Plan to pay for the office visit. You say that the cost of the initial consultation is way out of line 
and the max you will pay is $200. The Plan denied your request. The Plan says Medicare only covers manual 
manipulation of the spine to correct a subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on December 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 17, 
2021. 
 
You asked the Plan to pay for the services. You say that CPT codes 63011 and 63047 are documented in the 
medical record and should be reimbursed. The Plan denied your request. The Plan says procedure code 63011 
is not supported by the medical records submitted and CPT code 63047 is considered inclusive to CPT code 
22633. 
 
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 the denied codes is: 
 
63011 - laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without 
facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral 
 
63047 - laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal 
cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found in terms of CPT 63057, this procedure 
overlaps with CPT 22633, and does not include documentation to support increased effort for decompression, 
and therefore modifier -59 is not supported. In terms of CPT 63011, the operative report does not include 
documentation of laminectomy with exploration, sacral and therefore cannot be verified. 
 
We looked at this coder'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 surgical services provided to the enrollee on August 17, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for intraoperative neuromonitoring provided to the enrollee on November 
30, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this was not submitted with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that intraoperative neurophysiologic monitoring 
during thyroid surgery is considered reasonable and 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 pay for the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the procedure underwent by the enrollee was said to have been a total thyroidectomy. The LCD 
states that intraoperative neuromonitoring (IONM) is appropriate during a "removal of the thyroid." In as much 
as this fact, it can be concluded that the these services were then provided during a covered procedure. 
 
We looked at this physician's review, the file, and Medicare rules. The plan's denial reason is invalid. In the 
cited Local Coverage Article, there is indeed a list of diagnosis codes that support medical necessity. However, 
the list does not explicitly say that the diagnosis codes are the only appropriate diagnosis codes for these 
services. Additionally, the billed diagnosis code - E04.2 - is not listed under "Diagnosis Codes That Do Not 
Support Medical Necessity." Based on this information, we decided that Medicare rules for coverage of the 
services have been met. Therefore, we decided that the Plan has to pay for intraoperative neuromonitoring 
provided to the enrollee on November 30, 2021.  
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy with lesion removal (45385), anesthesia 
(00811), laboratory service (88305), electrodes (A4556), and the nasal application device (A7034) rendered by 
the out-of-network (OON) provider on August 4, 2021. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the items/services were rendered by an 
out of network provider, without prior authorization. 
 
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 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 
items/services 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 colonoscopy with lesion removal (45385), 
anesthesia (00811), laboratory service (88305), electrodes (A4556), and the nasal application device (A7034) 
rendered by the out-of-network (OON) provider on August 4, 2021.