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

 
We decided that the Plan does not have to pay for an office visit provided on October 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the provider is enrolled and an in-network provider 
with the Plan. Therefore, the services are payable. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 an office visit provided on October 22, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78830 billed for date of service September 
20, 2021. 
 You asked the Plan to pay for procedure code 78830. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 78830 is bundled into payment for 
code 79445. 
 
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 78830 
is a column II code to column I code 79445. 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 78830 billed for date of service September 20, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement (36247) and angiography 
(75716) provided on February 17, 2021. 
  You asked the Plan to pay for the selective catheter placement (36247) and angiography (75716). You say that 
the medical records submitted warrant payment for services performed as this procedure was medically 
necessary based on the patients history. The Plan denied your request. The Plan says CPT code 36247 and 
75716 are considered inclusive to CPT code 37224. 
 
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 codes 36247 and 75716 are column II codes to column I code 37224; 
however, 36247 and 75716 were billed with a modifier.  
 
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 selective catheter placement (36247) and angiography 
(75716). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found that catheter placements in the leg being revascularized are bundled into the 
lower extremity revascularization procedure. Procedure code 36247 would be inclusive to CPT 37224. 
Procedure code 75716 is being reported with CPT 36247, which is bundled into CPT 37224. Therefore, 
procedure code 75716 would also be bundled into CPT 37224. 
 
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 selective catheter placement (36247) and angiography (75716) have not 
been met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement (36247) 
and angiography (75716) provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation treatment (IMRT) 
delivery (77386, 77387, 99215) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve IMRT. You say that the requested services are a medical necessity for you. 
The Plan denied your request. The Plan says rules for coverage for out-of-network care have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
intensity-modulated radiation treatment (IMRT) delivery (77386, 77387, 99215) to be provided by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you want to see the rheumatologist to 
treat your fibromyalgia and rheumatoid arthritis. The Plan denied your request. The Plan says the services were 
requested at an out-of-network location, but can safely be provided by an in-network provider. The Plan also 
says the request will be re-routed to 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Ondansetron tablets are not covered under the 
enrollee's Medicare Part B 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 Ondansetron tablets.  
 
Benefits for Ondansetron tablets 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on October 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says Eliquis is not covered under the enrollee's Medicare Part B 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 Eliquis.  
 
Benefits for Eliquis 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physical therapy visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a physical therapy visit. You say that you were unable to obtain physical 
therapy services within a nearby Plan facility. The Plan denied your request. The Plan says the services have 
been requested from an out-of-network provider. Services are available from a network provider that is only 
0.2 miles away from the requested OON 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a physical therapy visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil tablets. 
 
You asked the Plan to pre-approve Tadalafil tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Tadalafil tablets are not covered under the enrollee's 
Medicare Part B 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 Tadalafil tablets.  
 Benefits for Tadalafil tablets 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 the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the Vertiflex procedure is considered experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current evidence based medical guideline and peer reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of 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 as discussed above. Food and Drug Administration (FDA) indications include 
implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal 
stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has 
multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis.  
FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of mild grade 1 anterolisthesis of L4 
on L5. With flexion this is mildly increased and with extension, the alignment is similar to neutral posture. 
With neutral posture, there is also grade 1 retrolisthesis of T12 on L1 without significant change between 
flexion and extension. There is no documentation of the enrollees height, weight or body mass index. 
There is imaging evidence of S-shape curvature with mild thoracolumbar levoconvex curvature and lumbar 
dextroconvex curvature with no documentation of the Cobb angle. There is no discussion indicating that a 
DEXA scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L4-5 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current evidence based medical guideline and peer reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of 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 as discussed above. Food and Drug Administration (FDA) indications include 
implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal 
stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has 
multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis (including the planned levels of implantation of L3-L4 and L4-5.) FDA contraindications include spinal instability, 
scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is 
imaging evidence of subtle at L4-L5 and L5-S1 anterolisthesis, with no discussion of spinal instability on 
flexion/extension films. Height 167 cm, weight 90.72 kg, and body mass index of 32.53 kg/m2. The DEXA 
scan has demonstrated osteopenia. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for 
Vertiflex Superion interspinous device at L3-L4 and L4-L5 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0301). 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that the item is medically 
necessary. The Plan denied your request. The Plan says you do not meet the weight requirements for this bed. 
 The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds but does not exceed 600 pounds. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy duty extra wide hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a heavy duty extra wide hospital bed (E0301).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G device. 
 
You asked the Plan to pre-approve MyoPro Motion G device. You say that this device is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested MyoPro device is considered 
experimental/investigational. 
 
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 MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve MyoPro Motion G device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of April 28, 
2022. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric care is 
correct. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer 
says that you do not meet the Medicare criteria for continued inpatient psychiatric care. Our physician reviewer 
found it is not expected that you will improve within a reasonable period of time beyond the date in question 
and you were not showing dangerousness to self or others, had no auditory or visual hallucinations, and had no 
aggressive behaviors. You were compliant and cooperative with treatment. It does not appear medically 
reasonable and necessary to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond April 28, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care as of April 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued skilled nursing facility (SNF) care to be 
provided by a network facility. 
 
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee has been in the hospital 
for a number of weeks and needs help with walking and functioning without getting dizzy. The Plan denied 
your request.  The Plan says authorization denied because continued SNF care is not medically necessary and the enrollee's 
needs can be met at a lower level of care such as outpatient therapy in residential long-term care, or home with 
home health services. 
 
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 the continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs that require skilled nursing services, including the specialized skill, knowledge and 
judgment of a skilled professional nurse required to safely and effectively provide medically necessary and 
reasonable treatment. There are identifiable skilled therapy service needs that require skilled therapy services, 
including the specialized skill, knowledge and judgment of a qualified therapist required to safely and 
effectively provide medically necessary and reasonable treatment. You do not require skilled nursing or therapy 
services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continued skilled nursing facility (SNF) care to be provided by a network 
facility.