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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 18, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 18, 
2022.
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 procedure is to allow mobility. You state that 
you have increased pain and disability almost daily despite exercises (PT) and chiropractor care. The Plan 
denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met as it has not 
been shown to be safe and effective in long term studies and there is a lack of evidence to support that 
interspinous spacer devices are as safe and effective as the gold standard of decompression. 
 
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 Vertilfex device is experimental, and 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the massage recliner chair (E1399). 
 
You asked the Plan to pre-approve the massage recliner chair. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says this item is not medical in nature 
and not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the massage recliner chair (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 13, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the attached records support this procedure 
was performed by the provider and the claim denied in error. You say that the claim should be reviewed and 
reprocessed for reimbursement. The Plan denied your request. The Plan says payment for code 71045 is 
bundled into payment for code 32555.  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 71045 
is a column II code to column I code 32555. 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 71045 billed for date of service January 13, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission after elective knee 
surgery. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the enrollee will benefit from 
having an inpatient stay after surgery. The Plan denied your request. The Plan says the requested inpatient 
hospital admission after elective knee replacement surgery does not meet the requirements for approval. 
 
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 pre-approve an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital admission is met in 
this case. Our physician reviewer found the enrollee has been approved for knee replacement surgery. He is 
medically stable and there is no documentation provided indicating medical necessity for the elective 
procedure. The review has determined that the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two 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 an inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission after elective knee surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breztri. 
 
You asked the Plan to pre-approve Breztri. You say that the enrollee has tried Breo Ellipta, Advair Diskus. You 
also say that Breztri will not be used in combination with another inhaler. The Plan denied your request. The 
Plan says Breztri is a self-administered drug, and does not fall under Part B coverage. 
 
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 Breztri.  
 
 
 
 
 Benefits for Breztri 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of hypoglossal nerve neurostimulator 
array (64582). 
 You asked the Plan to pre-approve hypoglossal nerve neurostimulation. You say that this service is medically 
necessary for this enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that hypoglossal nerve neurostimulation is considered 
medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea when 
certain criteria are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hypoglossal nerve neurostimulation have not been met. Specifically, the record notes that the 
enrollee's height is 64 inches, and their weight is 217 pounds. This means that the enrollee's BMI is 37.2, which 
does not meet the LCD requirement that the enrollee have a BMI less than 35. Therefore, we decided that the 
Plan does not have to pre-approve open implantation of hypoglossal nerve neurostimulator array (64582).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ SI joint stabilization system (CPT code 
27279). 
 
You asked the Plan to pre-approve the system. You say that the enrollee is experiencing debilitating pain and 
suffering. The Plan denied your request. The Plan says your request is not medically necessary because there 
the LinQ device is not an accepted standard of medical practice for the treatment of SI joint problems. The Plan 
states it is considered experimental and investigational. The Plan states the enrollee's magnetic resonance 
imaging (MRI) reveals spinal stenosis and thus, degenerative conditions that can be causing the enrollee's low 
back/buttock pain. 
 
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 system. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the LinQ SI stabilization device remains experimental, and more research is needed to show 
safety and efficacy. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the LinQ SI joint stabilization system (CPT code 27279).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nalu device for treatment of your trigeminal neuralgia 
(CPT code(s): L8680 and 64555). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says Nalu device has not been proven safe and effective to treat your 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this would be an off-label, unproven use of a peripheral nerve stimulator in the cranio-facial 
region. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nalu device for treatment of your trigeminal neuralgia (CPT code(s): L8680 and 64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(CPT code(s): 64628 and 64629). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intraosseous basivertebral nerve ablation is experimental and 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve (CPT code(s): 64628 and 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that sclerotherapy is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has spider 
veins/telangiectasis without evidence of bleeding. There is evidence of saphenous reflex that has not been 
treated. The record does not indicate the size of the spider veins. The criteria for coverage are not met and the 
sclerotherapy is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has shoulder osteoarthritis. 
He has not tried and failed the Plan's required drugs, Durolane, Euflexxa, Supartz FX, or Gelsyn-3. The records 
do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One is not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee continues to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that she would require skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status. She can receive further services at a lower level of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 SNF care. Our physician reviewer 
found the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on December 29, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered 
for CxBladder testing.  
 
We looked at the file and Medicare rules. Per LCD L35396, code 0013M is non covered for CxBladder testing. 
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on December 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $35 copayment for a virtual office visit on February 15, 
2022. 
 
You asked the Plan to waive the $35 copayment for a virtual office visit. You say that you should not be 
responsible for this copayment. The Plan denied your request. The Plan says you must pay a $35 copayment for 
each virtual office visit with a specialist 
 
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 $35 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $35 copayment for a virtual office visit. A virtual office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. 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 $35 copayment for a virtual office visit on February 15, 2022.