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

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device 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 
the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex 
superion device placement surgery (CPT code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the device evaluation provided on February 24, 2022. 
 
You asked the Plan to pay for the services provided. You say that the claim coded and billed appropriately. The 
Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 93294 is Interrogation device evaluation(s) (remote), up 
to 90 days; single, dual, or multiple lead pacemaker system, or leadless pacemaker system with interim 
analysis, review(s) and report(s) by a physician or other qualified health care professional.  
 
We find that CPT code 93294 is not supported in the medical record. The records do not include documentation 
for the date of service at issue. Furthermore, we find that code 93294 was previously billed and paid for by the 
same provider for date of service December 21, 2021. This code cannot be reported more than once every 90 
days. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the device evaluation provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that the ILR implant is necessary in order to diagnose and 
treat associated cardiac rhythm disorder. The Plan denied your request. The Plan says implantable loop 
recorders are not needed for routine assessment of patients with atrial fibrillation; therefore, it is not considered 
"standard of care." 
 
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 ILR. Our physician reviewer found 
there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any 
other apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in this enrollees clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ILR (CPT code 33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $25 copayment for a specialist visit on December 8, 2021. 
 
You asked the Plan to waive the $25 copayment for a specialist visit. You say that you should not be 
responsible for this copayment because you had already reached your out-of-pocket maximum. The Plan 
denied your request. The Plan says the cost share has been applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you have a combined 
out-of-pocket maximum of $2,500.  
 
 
 You have been asked to pay a $25 copayment for a specialist visit. At the time this claim was processed, your 
out-of-pocket maximum had not been met. 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 $25 copayment for a 
specialist visit on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided by an out-of-network (OON) provider on 
February 15, 2022. 
 You asked the Plan to pay for eyewear. You say that this provider is less expensive. The Plan denied your 
request. The Plan says the denial of payment for this item is correct, because this provider is out-of-network 
with the Plan and you did not receive authorization. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services from an out-of-network provider when authorization is received. 
 
We looked at the file and the Plan's rules. You did not receive authorization to use this out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for eyewear provided by an out-of-network 
(OON) provider on February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prostate Artery Embolization (PAE) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness or prostate artery embolization 
(PAE) in the setting of Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms (BPH-LUTS) has 
not been demonstrated in the peer-reviewed 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Prostatic arterial 
embolization (PAE) is considered an experimental technique to treat symptomatic Benign Prostatic 
Hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most 
recent AUA guidelines do not recommend this procedure outside of a clinical trial setting due to the 
heterogeneity in the available literature and safety concerns regarding radiation exposure, postembolization 
syndrome, vascular access, technical feasibility, higher clinical failure rate compared with more traditional 
methods. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prostate Artery Embolization (PAE) for the enrollee.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility. 
 
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. Our 
physician reviewer found that while the enrollee would benefit from physical therapy, and occupational 
therapy, his rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a 
skilled nursing facility. 
 
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 lab services provided on November 12, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
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 lab 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 lab services 
provided on November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedic footwear and inserts. 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show 
that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics 
may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the 
enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve the orthopedic footwear 
and inserts.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medication management services. 
 
You asked the Plan to pre-approve the medication management services. You say that the enrollee needs help 
with managing meds. You state the enrollee takes blood pressure and psychiatric medications. You state the 
enrollee sometimes forgets to take them and they cannot take their medications properly. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Medication 
management of self-administered medication is a type of custodial care and is considered not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member and is not covered. Therefore, we decided that the Plan does not have to pre-approve the medication 
management services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the out-of-network deductible and coinsurance for the 
laboratory services (88305, 88314, 88341, 88342, 88356) provided March 14, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to waive the out-of-network deductible and coinsurance for the OON laboratory services. 
You say that you would like and exception for the enrollee's claim to be reprocessed based on in-network 
benefits. The Plan denied your request. The Plan says the claim has processed correctly based on the enrollee's 
OON benefits. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 50% coinsurance after the enrollee's $770 plan deductible is met for each Medicare-covered lab 
service when provided OON. 
 
The enrollee has been asked to pay 50% coinsurance after the enrollee's $770 plan deductible was met for the 
OON laboratory services. The OON laboratory services fall within the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. A prior authorization was not submitted for an OON 
exception. There are no exceptions that would require the Plan to cover this claim as in-network. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the out-of-network deductible and coinsurance for the laboratory services (88305, 
88314, 88341, 88342, 88356) provided March 14, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PRBT (CPT code 77525). 
 
You asked the Plan to pre-approve the PRBT. You say that the enrollee has the right to choose proton beam 
therapy treatment and the doctor is able to control the depth of radiation administered to limit the dose to critical structures. The Plan denied your request. The Plan says routine costs associated with the enrollee's 
clinical trial should be billed to Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the PRBT as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve PRBT (CPT code 77525).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on December 4, 2021. 
 
You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says code 01820 has a Procedure-to-Procedure (PTP) edit of 0 with code 25505 
so 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 01820 
is a column II code to column I code 25505 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for anesthesia provided on December 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this admission does not meet criteria. 
 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee does not have any parenteral medication, complex wound care or nutrition given via a feeding tube. 
The enrollee is medically stable without any acute exacerbations of chronic medical problems. Physical 
function is at or near the baseline, and the enrollee can receive services at a lower level of care. Admission to a 
SNF for inpatient skilled rehab services is 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
February 22, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not payable as they were not 
purchased from the Plans select hearing aid provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the items in this case were purchased from an out-of-
network provider. The Plan contract states that hearing aids are purchased from the Plans select hearing aid 
provider. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids 
(V5298) purchased on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 9, 2022, billed with 
codes 81225 and 81226. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these services were not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 9, 2022, billed with codes 81225 and 81226.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99100 billed for date of 
service February 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on February 5, 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 references Local Coverage Article (LCA) A53628 in their 
determination; which is not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the FANCC genetic testing rendered on February 5, 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.