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

 
We decided that the Plan does not have to pre-approve radiation and chemotherapy treatment to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there are in-network providers that can provide the services. 
 
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 radiation and 
chemotherapy treatment to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure cuff. 
 
You asked the Plan to pre-approve a blood pressure cuff. You say that you need this because of your high 
blood pressure. The Plan denied your request. The Plan says this is not covered for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that a blood pressure apparatus is covered for the 
treatment of end stage renal disease.  
 
We looked at the file and Medicare rules. The record does not show that you have end stage renal disease. 
Based on this information, we decided that Medicare rules for coverage of a blood pressure cuff have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a blood pressure cuff.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that this is a request for continued inpatient 
care at a skilled nursing facility. The Plan denied your request. The Plan says you do not meet the requirements 
for approval. 
 
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 SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found your prior tracheotomy 
and more recent feeding tube are established. You do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. Your care 
needs, custodial care and intermittent, can, as a practical matter, be provided 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 a SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SNF admission.
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 it is necessary that the member be approved for 
admission to your acute inpatient rehabilitation facility to receive his port-acute rehabilitation prior to 
discharging home. The Plan denied your request. The Plan says the member is not medically stable for 
admission to an Inpatient Rehabilitation Facility (IRF). 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that there are no complex nursing or rehabilitation needs. Our physician reviewer also 
found the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program, and medically necessary care can be 
provided in a different 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nephrostomy catheter placement provided on November 
9, 2021, billed with code 50432-XU. 
 
You asked the Plan to pay for the catheter placement as billed. You say that this should be paid as billed. The 
Plan denied your request. The Plan says there is no evidence to support separate payment for 50432.  
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 50432 is a column II code to column I code 50562; however, 50432 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the catheter placement as billed. Our reviewer says that the 
documentation does not support the use of modifier -XU to bypass the PTP edit in this case. Our reviewer 
found the operative report describes catheter placement and renal endoscopy was performed on the same side. 
In this situation, catheter placement would not be reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the catheter placement as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the nephrostomy catheter placement provided on November 9, 2021, billed 
with code 50432-XU.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve back (fusion) surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of failed non-surgical treatment. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of a recent trial and failure of physical therapy for low back pain. Fusion is not 
needed 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve back (fusion) surgery.
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 enrollee needs admission to an IRF to reach a full 
recovery. You also say the enrollee is at a critical point for regaining function and will be at risk of not 
achieving full function if admission to an IRF is delayed. The Plan denied your request. The Plan says the 
denial of IRF admission was processed correctly. The Plan says the enrollee's medical needs do not meet the 
criteria IRF admission. The enrollee does not require the complexity of care that an IRF provides. The 
enrollee's needs can be met at a lower level of care, such as a Skilled Nursing Facility (SNF). 
 
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 has a past medical history of stroke with left-sided weakness, Chronic 
Obstructive Pulmonary Disease (COPD), and a meniscus tear. The enrollee is currently living at home 
receiving home health services. Our reviewer found the enrollee's medical problems are stable and there are no 
complex nursing or rehabilitation needs that would require admission to an IRF.  
 
The medical records support physical and/or occupational therapy needs, but there is no documentation 
supporting the need for intensive rehabilitation services. Therefore, our physician reviewer says the enrollees 
medically necessary care can be provided in a different setting with a lower level of care. Furthermore, there is 
no reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program that an IRF offers. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) provided 
on November 3, 2021. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you believe this claim 
should have been processed as an outpatient vision care physician service and the copayment should be waived. 
The Plan denied your request. The Plan says this claim was processed correctly. 
 
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. 
 
We looked at the file and the Plan's rules. You are responsible for a $15 copay for each Medicare-covered eye 
exam service. Based on this information, we decided that the Plan's rules for coverage of the outpatient office 
visit have not been met. Therefore, we decided that the Plan does not have to waive the copayment for the 
outpatient office visit (99214) provided on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the service was 
provided out-of-network and was not approved in advance. 
 
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 the office visit provided on January 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital hearing aids and shipping provided on April 16, 
2019. 
 
You asked the Plan to pay for the digital hearing aids and shipping. You say that the reason you sent the claim 
late was because the provider told you that the Plan does not pay anything, and you would have to pay full 
price. You also say that you saw on the television that Medicare would cover some of this service. The Plan 
denied your request. The Plan says this claim was submitted after the filing deadline. 
 
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 claim for the digital hearing aids and shipping was not filed until February 16, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the digital hearing aids and shipping provided on 
April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on May 3, 
2021, and May 10, 2021. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that medical records are attached 
for review and the claim should be processed for payment. The Plan denied your request. The Plan says only 
manual manipulation of the spine to correct subluxation is covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
 
  The records show that the chiropractic manipulative treatment at issue is not manual manipulation of the spine. 
Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment provided on 
May 3, 2021, and May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services (CPT code 99204) to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the office services. You say that your current pulmonary specialist is not 
attentive to your health condition. The Plan denied your request. The Plan says there are in-network providers 
that can provide the services. 
 
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 the office 
services (CPT code 99204) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept procedure at L3-4, L4-5 and L5-S1 vertebral 
bodies. 
 
You asked the Plan to pre-approve intracept procedure at L3-4, L4-5 and L5-S1 vertebral bodies. You say that 
this procedure is medically necessary. The Plan denied your request. The Plan says the requested intracept 
procedure is 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 intracept procedure at L3-4, L4-5 and 
L5-S1 vertebral bodies. Our reviewer says that the requested intracept procedure is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that all of the published studies address  
one or two vertebral bodies, not three. The studies excluded patients over 70 years old. There is no evaluation 
of the enrollees bone density. This is considered an experimental, investigational procedure. 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 intracept procedure at L3-4, L4-5 and L5-S1 vertebral bodies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve intracept procedure at L3-4, L4-5 and 
L5-S1 vertebral bodies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
November 23, 2021 to Ferbruary 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the continuous glucose monitor (CGM) supplies rendered on 
November 23, 2021 to Ferbruary 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthetic and accessories to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the services may be obtained in-network. 
 
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 the prosthetic 
and accessories to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (A9270). 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that elastic stockings are not covered because they are non-
reusable supply items. Elastic stockings are not durable medical equipment. 
 
Although this item may be appropriate for you, it does not fall into a covered benefit category and cannot be 
paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve 
compression stockings (A9270).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in severe pain. The Plan denied 
your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal 
fusion surgery have not been demonstrated. 
 
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 that bone marrow aspirate remains 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for the enrollee.