Persius/hicric huggingface dataset:
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 were admitted to the hospital and 
treated by this provider. You also say you were told to follow up with this provider after you were discharged 
from the hospital. The Plan denied your request. The Plan says two participating providers have been identified 
as accepting new patients, covered under your plan. The Plan also says there are no gaps in care or continuity 
of care issues identified. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and segmental 
pneumatic appliance (E0673) provided August 20, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting for this claim 
to be re-evaluated. The Plan denied your request. The Plan says pneumatic compression device is not covered 
by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) and segmental pneumatic appliance (E0673) provided August 
20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 5, 2022, to January 19, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and the member doesn't have OON 
benefits. 
 
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 January 5, 2022, to 
January 19, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on February 18, 2022. 
  You asked the Plan to pay for the CT scan (70450). You say that the patient had multiple exams on this date of 
service and the attached reports support the level of service. You say that claim should be reconsidered for 
processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit. 
 
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 the CT scan (70450) provided on February 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on November 2, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory testing provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you for the transplant related lodging, meals and transportation 
(S9975) provided from January 12, 2022, through February 23, 2022. 
 
You asked the Plan to reimburse you for the transplant related lodging, meals and transportation. You say that 
you continue to require lodging and transportation services related to the transplant care. The Plan denied your 
request. The Plan says that there is no lodging and transportation fee for cancer care. 
 
The Plan must follow Medicare rules. Medicare rules say that when the Plan provides transplant services at a 
distant location, farther away than the normal community patterns of care for transplant services, they must 
provide reasonable travel and lodging. The Plans contract says that the Plan provides transplant services at a 
location outside the pattern of care for transplants in your community and if you choose to obtain transplants at 
this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a 
companion. 
 
We looked at the file and Medicare rules. In this case, the Plan is required to coordinate your transplant care. It 
is noted that you have signed a contract to stay in the area where the transplant was performed for a year. There 
is no convincing evidence that the Plan has coordinated care with in-network providers that would continue to 
be able to care for your transplant needs. Furthermore, there is no evidence that the Plan provided notice to you 
that they would not pay for the full year of services related to the transplant care. There is also evidence 
provided from the transplant provider that you are not yet ready to leave the transplant area due to ongoing 
medical circumstances. The evidence does not support the Plans argument that the enrollee is ready to leave 
the area where the transplant was performed. Therefore, the associated lodging, meals and transportation 
associated with the transplant must continue to be paid by the Plan at this time. 
 Based on this information, we decided that Medicare rules for coverage of the transplant related lodging, meals 
and transportation have been met. Therefore, we decided that the Plan has to reimburse you for the transplant 
related lodging, meals and transportation (S9975) provided from January 12, 2022, through February 23, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the complexity of your nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lumbar spinal surgery. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 20, 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 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 January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro power-assisted arm brace. 
 
You asked the Plan to pre-approve the MyoPro brace. You say that it is felt that this is needed because the 
enrollee has been unable to regain function with standard therapies. The Plan denied your request. The Plan 
says this is not proven to be an effective treatment for the enrollee's condition. 
 
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 MyoPro brace. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of 
the patient's medical condition/function of hemiparesis after stroke than any available standard therapies, such 
as conventional treatments for post-stroke hemiparesis therapy, including constraint-induced movement 
therapy, conventional muscle strengthening, and Botox for spasticity if needed. The requested device is not 
reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. 
 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 the MyoPro brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the MyoPro power-assisted arm brace.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection services. 
 
You asked the Plan to pre-approve sacroiliac joint injection services. You say that you will slowly lose ability 
to walk should you not receive the requested injections. The Plan denied your request. The Plan says the 
records do not document specific provocative testing of the sacroiliac joint to try and more carefully evaluate 
that area specifically. 
 
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 sacroiliac joint injection services. Our 
reviewer says that sacroiliac joint injection services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation on physical examination of three or more 
positive tests results.  The clinical value and effectiveness of an sacroiliac joint injection in the absence of 
tenderness and negative provocative testing results have not been demonstrated in the peer-reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve sacroiliac joint injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that there is sufficient science published in 
peer-reviewed publications showing that the requested procedure is appropriate. You say that the requested 
procedure improves the quality of life of patients suffering from vertebrogenic low back pain. The Plan denied 
your request. The Plan says the requested procedure is considered experimental/investigational as it is not 
widely used or generally accepted for the suggested use as reported in nationally recognized peer-reviewed 
medical literature. 
 
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 an Intracept procedure. Our reviewer 
says that an Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic low back pain. Our physician reviewer found that the 
Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services 
 
You asked the Plan to pre-approve the physical therapy services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says This request is not medically necessary. Care needs can 
be met at a lower level of care. 
 
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 the physical therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the documentation does not reveal that the enrollee 
requires the unique skills of a professional therapist to provide treatment safely and effectively, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve physical therapy services
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for the transplant related lodging, meals and transportation 
(S9975) provided from December 1, 2021, through December 30, 2021. 
 
You asked the Plan to reimburse you for the transplant related lodging, meals and transportation. You say that 
you continue to require lodging and transportation services related to the transplant care. The Plan denied your 
request. The Plan says that there is no lodging and transportation fee for cancer care. 
 
The Plan must follow Medicare rules. Medicare rules say that when the Plan provides transplant services at a 
distant location, farther away than the normal community patterns of care for transplant services, they must 
provide reasonable travel and lodging. The Plans contract says that the Plan provides transplant services at a 
location outside the pattern of care for transplants in your community and if you choose to obtain transplants at 
this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a 
companion. 
 
We looked at the file and Medicare rules. In this case, the Plan is required to coordinate your transplant care. It 
is noted that you have signed a contract to stay in the area where the transplant was performed for a year. There 
is no convincing evidence that the Plan has coordinated care with in-network providers that would continue to 
be able to care for your transplant needs. Furthermore, there is no evidence that the Plan provided notice to you 
that they would not pay for the full year of services related to the transplant care. There is also evidence 
provided from the transplant provider that you are not yet ready to leave the transplant area due to ongoing 
medical circumstances. The evidence does not support the Plans argument that the enrollee is ready to leave 
the area where the transplant was performed. Therefore, the associated lodging, meals and transportation 
associated with the transplant must continue to be paid by the Plan at this time. 
 
Based on this information, we decided that Medicare rules for coverage of the transplant related lodging, meals 
and transportation have been met. Therefore, we decided that the Plan has to reimburse you for the transplant 
related lodging, meals and transportation (S9975) provided from December 1, 2021, through December 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11057-GY billed for date of service January 
6, 2022. 
 
You asked the Plan to pay for procedure code 11057-GY. You say that this claim was billed appropriately and 
should be reprocessed. The Plan denied your request. The Plan says this service is not billed with the modifier 
you appended. 
 
The Plan must follow Medicare rules. Medicare rules say that the GY modifier indicates that the item or service 
is statutorily excluded or does not meet the definition of any Medicare benefit. This means that any service 
billed with the GY modifier is not covered.  You billed the service in question with the GY modifier. Based on 
this information, we decided that Medicare rules for coverage of procedure code 11057-GY have not been met.  
 
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for procedure code 11057-GY billed for date of 
service January 6, 2022.