Persius/hicric huggingface dataset:
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
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 reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily nursing or therapy services. The enrollee does 
not meet the severity of illness or the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) you received on 
March 4, 2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says this provider is not 
enrollee in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) 
you received on March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 95941. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service April 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a diagnostic colonoscopy provided on April 25, 
2022. 
 
You asked the Plan to waive the cost for a diagnostic colonoscopy. You say that this was supposed to be a 
screening, with no copayment. The Plan denied your request. The Plan says this cost sharing was charged 
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 must pay a 20% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. The allowed amount of this service or item is $488.91, resulting in a coinsurance of $97.78 
($488.91 x 20% = $97.78). Your maximum out of pocket (MOOP) amount is $6700 for the year. A total of 
$568.40 has been applied to your MOOP ($97.78 + $470.62 = $568.40). 
 
 You have been asked to pay a $568.40 coinsurance for a diagnostic colonoscopy. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 cost for a diagnostic colonoscopy provided on 
April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis C antibody screening, for individual at high risk 
and other covered indications (G0472) provided February 16, 2022. 
 
You asked the Plan to pay for the screening service. You say that you would like to appeal for payment of the 
claim since your new PCP never knew that the test was already administered. The Plan denied your request. 
The Plan says the benefit limit has been reached and no payment can be issued for this service. 
 
The Plan must follow Medicare rules. The rules say that Hepatitis C Screening is covered once in a lifetime for 
people that were born between 1945 and 1965, who are not considered high risk.  
 
We looked at the file and Medicare rules. The records show that the enrollee previously had a Hepatitis C 
screening on June 14, 2019. Based on this information, we decided that Medicare rules for coverage of the 
screening service have not been met. Therefore, we decided that the Plan does not have to pay for the Hepatitis 
C antibody screening, for individual at high risk and other covered indications (G0472) provided February 16, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the device is needed to keep 
the range of motion up to maximum function after being discharged from hospital. The Plan denied your 
request. The Plan says the device is not covered. 
 
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 pre-approve a pneumatic 
compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (MBBs) (64494, 64493). 
 
You asked the Plan to pre-approve MBBs. You say that you do not want to have surgery. You say that you 
want to continue with the shots. You say that the shots provide 6 months of relief. You also say that you do not 
want to treat your pain with opiates. The Plan denied your request. The Plan says the injections are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary pain. 
 
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 MBBs. Our reviewer says that the 
requested MBBs are not medically necessary. Our physician reviewer found the provided documentation does 
not support that you had at least 80% pain relief from the previous MBBs. Therefore, the reviewer found that 
the requested MBBs are 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 MBBs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve medial branch blocks (MBBs) (64494, 64493).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept back procedure (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 medical studies have not proven that the service(s) or procedure(s) is helpful for 
treatment of the enrollee's health problem. 
 
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 documentation was/is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested intracept intraosseous basivertebral nerve ablation at L3, L4, and L5, in this 
case, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept back procedure (CPT code(s): 64628 and 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT). 
 
You asked the Plan to pre-approve myocardial perfusion imaging (SPECT). You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing 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 myocardial perfusion imaging 
(SPECT). Our reviewer says that the services are not medically necessary. Our physician reviewer found there 
is no evidence provided that would support the need for radionuclide stress testing. In summary, there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing 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 myocardial perfusion imaging (SPECT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on September 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed". 
 We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested on the date of service in question. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0020 billed for date of service July 28, 
2022. 
 
You asked the Plan to pay for procedure code S0020. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0020 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0020 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0020 billed for date of service July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (64635, 64636, and J1030) provided 
on January 11, 2021. 
 
You asked the Plan to pay for procedure codes 64635, 64636, and J1030. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the corrected claim was not 
filed timely per Medicare guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a corrected claim for procedure codes 64635, 64636, and J1030 was not filed until May 
12, 2022. This means that more than one calendar year from the date of service had passed before a corrected 
claim was filed. Therefore, we decided that the Plan does not have to pay for the physician services (64635, 
64636, and J1030) provided on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic CGM (CPT code K0553) provided on March 
30, 2022. 
 
You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the CGM have not been met. Review of the file shows that it did 
not include a patient receipt or proof of delivery of the therapeutic CGM for the billed date of service of March 
30, 2022. The submitted proof of delivery is for a different date of service, March 7, 2022. Therefore, we 
decided that the Plan does not have to pay for the therapeutic CGM (CPT code K0553) provided on March 30, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the seat lift mechanism, electric, any type (E0627) 
provided January 10, 2022. 
 You asked the Plan to reimburse you for the seat lift mechanism. You say that the enrollee was in Florida and 
broke their arm. The enrollee was unable to lay down in their condition so a chair was rented. The Plan denied 
your request. The Plan says the records do not support that the criteria has been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism.  
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. The record the records also does not contain a valid physician 
order for the item provided in this case. The records also show that the item is not a seat lift mechanism, but an 
actual chair with a lift. Therefore, we decided that the Plan does not have to reimburse you for the seat lift 
mechanism, electric, any type (E0627) provided January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) device (L8680, 63650). 
 
You asked the Plan to pre-approve SCS device. You say that the enrollee has tried multiple treatments since 
their accident with no relief. You also say that the enrollee is a great SCS candidate. The Plan denied your 
request. The Plan says the requested SCS is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions have been 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 SCS device. Our reviewer says that the 
requested SCS device is not medically necessary. Our physician reviewer found the provided documentation 
does not include current imaging. Therefore, the reviewer found that the requested SCS device is not medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SCS device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) device (L8680, 63650).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel and lodging expenses (A0425, S9975, S9977) 
provided on June 2, 2022. 
 
You asked the Plan to pay for the travel and lodging expenses. You say that these services should be covered. 
The Plan denied your request. The Plan says these services are not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not 
covered. Medically necessary services are those that are reasonable and necessary for the diagnosis or treatment 
of an illness or injury. The plan covers some travel expenses for enrollees who require an organ transplant. 
 
We looked at the file and Medicare rules. Travel and lodging expenses are not covered by Medicare. The plan 
benefit for travel and lodging is only applicable for enrollees who require inpatient hospital care for an organ 
transplant. The record shows there was no transplant services. Based on this information, we decided that 
Medicare rules for coverage of the travel and lodging expenses have not been met. Therefore, we decided that 
the Plan does not have to pay for travel and lodging expenses (A0425, S9975, S9977) provided on June 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurology evaluation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the out-of-network neurology evaluation. You say that the out-of-network 
services are medically necessary. The Plan denied your request. The Plan says there are network providers 
available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
neurology evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy before coverage can be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a holding chamber/spacer for an inhaler or nebulizer 
without a mask. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) is covered 
when it can withstand repeated use and meets other criteria. 
 
We looked at the file and Medicare rules. The file shows that the requested item is disposable and cannot 
withstand repeated use. 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 a holding 
chamber/spacer for an inhaler or nebulizer without a mask.