Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup manual wheelchair. 
 
You asked the Plan to pre-approve a backup manual wheelchair. You say that you cannot fold an electric 
wheelchair and take it in your car and go anywhere. You need the requested wheelchair for doctors 
appointments. The Plan denied your request. The Plan says you currently have an electric wheelchair, and 
backup chairs are not reasonable and necessary. Additionally, the wheelchair is being used outside of the home, 
it is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a backup manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided to the enrollee on March 21, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that the provider should have verified the member's eligibility, health 
benefits and obtained authorization prior to the member s visit before providing services to the member. 
 
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 to the enrollee on March 
21, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided to the enrollee on June 13, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that services from non-participating providers are not covered under the 
enrollee's plan unless they are authorized before the services are provided. 
 
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 to the enrollee on June 13, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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. Our 
physician reviewer found that the enrollee appears to be more stable and improving and still requires short-term 
additional acute care services that can be safely provided at the current facility until more stable for transfer to 
a lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the abdomen and pelvis; 
with contrast material(s) (74177). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that the submitted handwritten records 
provided are essentially illegible. It appears that the enrollee had abdominal pain at the last clinic visit which 
was over five weeks ago on October 6, 2022. At that time the enrollee was afebrile. No acute abdominal signs 
were apparent in the records that could be understood. There was no lab work included in the records. The 
enrollee has not had an ultrasound of the abdomen and the current symptomatology is not assessed beyond 
October 6, 2022.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT), of the abdomen and pelvis; with contrast material(s) (74177).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related osteoporosis without osteoporotic fracture. The documentation does not 
indicate that the enrollee has tried and failed an oral bisphosphonate drug (e.g., alendronate, ibandronate, 
risedronate) and zoledronic acid (generic Reclast). The documentation does not support that an oral 
bisphosphonate drug (e.g., alendronate, ibandronate, risedronate) and zoledronic acid (generic Reclast) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 4, 
2022. 
 You asked the Plan to pay for procedure code 99053. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 49406 billed for date of service February 27, 2022. 
 
You asked the Plan to pay for code 49406. You say that this code is not bundled into payment for any other 
code on that date of service. The Plan denied your request. The Plan says this service was performed during the 
10-day global period for surgery code 10160, so it is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that for each surgery performed, there is a global 
surgical period that applies.  During that global period, certain related services are not separately payable. 
 
In this case, you billed for a minor surgery (code 10160) for date of service February 23, 2022.  This minor 
surgery has a 10-day global period, meaning that most services performed during this 10-day period would not 
be separately payable.  You then billed code 49406 for date of service February 27, 2022, which is within the 
10-day global period.  While this service may not have been related to the original procedure, you did not bill 
with a modifier that would indicate that code 49406 is a clearly distinct or unrelated procedure. A variety of 
modifiers could be used to indicate that this procedure is unrelated to code 10160, but you did not bill any of 
these modifiers. Without such a modifier appended, this second procedure is considered part of the global 
package and separate payment is not allowed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 49406 have not been met. Therefore, we decided that the Plan does not have to pay for code 
49406 billed for date of service February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment with warranty you purchased on April 
11, 2022. 
 
You asked the Plan to pay for the oxygen equipment with warranty.. You say that you have extreme problems 
with mobility and are prone to falls. You said that the system you purchased is lightweight and easier for you to 
use with a walker or a cane. You said that a rental would be more expensive because you will need oxygen for 
the rest of your life. The Plan denied your request. The Plan says purchased oxygen equipment and sales 
warranties are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. In addition, Medicare does not cover items 
and services not directly related to the treatment of an illness or injury or to improve the functioning of a 
malformed body member. Since you purchased this oxygen system, it is non-covered.  Medicare does not cover 
purchased oxygen equipment. Also, the sales warranty is not directly related to the treatment of an illness or 
injury, so that cost is not covered either. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen equipment with warranty. have not been met. Therefore, we decided that the Plan does 
not have to pay for the oxygen equipment with warranty you purchased on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service March 15, 
2022. 
 You asked the Plan to pay for procedure code 99053. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is a medical necessity. The 
Plan denied your request. The Plan says admission to the LTACH was denied as is it not medically necessary. 
 
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. Our 
physician reviewer found the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
 
 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollees status is stable and improving. The 
enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital, and there are no issues for which 
LTACH may offer a therapeutic advantage. 
 
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. Our 
physician reviewer found the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that this is the most appropriate treatment 
for the enrollee. The Plan denied your request. The Plan says unproven procedures are not covered by 
Medicare. 
 
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 requested services.  Our physician 
reviewer found that the requested Vertiflex device is experimental. More research is needed to show its safety 
and efficacy. Therefore, the request is not considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex interspinous stabilization device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried conventional 
treatment options. The Plan denied your request. The Plan says the request does not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that electric nerve stimulators are only covered under 
certain medical indications.  
 
 
 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 requested services. Our physician 
reviewer found that the enrollee has a thoracic vertebral body compression fracture. He has had 2 sets of 
diagnostic medial branch blocks which have produced 80-90% pain relief for the duration of the local 
anesthetic. He has not had radiofrequency ablation of the medial branches. The request is for placement of 
peripheral nerve stimulators in the thoracic region. There is not enough clinical evidence to support the efficacy 
of peripheral nerve stimulation in the thoracic 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT peripheral nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic spinal puncture provided on 
May 13, 2022. 
 
You asked the Plan to waive the copayment for therapeutic spinal puncture. You say that you were told you 
would not have any copayment, and now you received a bill for $295. You also say that the shot did not help 
with the pain. 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay a $295 copayment for therapeutic spinal puncture. This item/service falls within 
the Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but 
not limited to hospital or other facility charges and physician or surgical charges 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 copayment for therapeutic spinal puncture provided on May 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is weak and can only be moved around 
with supervised help. You say that the longer the enrollee is without rehab the worse they will get and will be 
at a higher risk for falling. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee can safely receive the care they need in another setting. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging provided on 
July 22, 2022. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging. You say that the cost share is a 
financial hardship at this time. 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 $250 
copayment for MRI. 
 
You have been asked to pay a $250 copayment for magnetic resonance imaging. This item/service falls within 
the MRI 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 copayment for magnetic resonance 
imaging provided on July 22, 2022.