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

 
We decided that the Plan does not have to pre-approve an inpatient stay for a knee surgery. 
 
You asked the Plan to pre-approve the inpatient stay. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this procedure can safely be performed in an outpatient setting. 
 
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 inpatient stay. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no detailed documentation regarding a significant past or current medical history that 
would place this enrollee at increased risk for surgical complications requiring an inpatient stay. 
 
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 inpatient stay have not been met.  
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve an inpatient stay for a knee surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paravertebral facet joint injections (64494-RT and 
64494-LT) provided on February 9, 2022. 
 
You asked the Plan to pay for codes 64494-RT and 64494-LT. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of codes 
64494-RT and 64494-LT have not been met. Code 64494 has a bilateral surgery indicator of "1" and must be 
reported with 1 unit of service and modifier 50 (bilateral modifier). Therefore, we decided that the Plan does 
not have to pay for the paravertebral facet joint injections (64494-RT and 64494-LT) provided on February 9, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance 
(E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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 
pay for a pneumatic compression device (E0675) and appliance (E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod insulin pump. 
 
You asked the Plan to pre-approve the requested services. You say that this is not a disposable pump. The Plan 
denied your request. The Plan says Omnipods are not covered as durable medical equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Disposable drug delivery systems are non-covered because they do 
not meet the definition of durable medical equipment. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
Omnipod insulin pump.  
 
 Benefits for the requested services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical epidural steroid injections. 
 
You asked the Plan to pre-approve the requested services. You say that you are in constant pain. The Plan 
denied your request. The Plan says the documentation does not support a diagnosis of cervical radiculopathy. 
 The Plan follows Medicare rules. Medicare rules say that epidural steroid injections 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 you have chronic neck pain. There is no documentation of a cervical radiculopathy, 
imaging or other physical examination/history which supports this request. Therefore, the request is considered 
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 cervical epidural steroid injections.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve trigger point injection services. 
 
You asked the Plan to pre-approve trigger point injection services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says that the Medicare coverage 
criteria for trigger point injection services have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that trigger point injections are subject to the criteria 
listed 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 trigger point injection services. Our 
reviewer says that the requested injections are medically reasonable and necessary per Medicare rules. Our 
physician reviewer found the enrollee has chronic neck pain. She has shoulder pain, and the pain radiates from 
a trigger point. She notes a locked-up feeling. Trigger point was identified on an ultrasound scan. In this case, 
the documentation supports that the criteria for coverage have been satisfied. The requested trigger point 
injections are medically reasonable and 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 trigger point injection services have been met. Therefore, we decided that the 
Plan has to pre-approve trigger point injection services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary to facilitate 
increased independence and to return home with an improved quality of life. The Plan denied your request. The 
Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower level of care such 
as in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there is no current clinical information that shows the enrollee would be able to 
tolerate intense therapy that an IRF would provide. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for a specialist office visit and 
skin growth destruction provided on January 25, 2022. 
 
You asked the Plan to waive the deductible and copayment for the office visit and skin growth destruction. You 
say that the procedure did not help and you feel that you should not have to pay. The Plan denied your request. 
The Plan says the correct deductible amount and copayment were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $150 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay $100 copayment for surgical services in a 
specialist's office after the deductible is met. 
 
The office visit you asked the Plan to waive the deductible for falls within the Physician/Practitioner Services, 
Including Doctors Office Visits benefit category. The skin growth destruction you asked the Plan to waive the deductible and copayment for falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $150 deductible which applies to certain items and services. This 
cost sharing is a contractual obligation that had not been met at the time the office visit and skin growth 
destruction was received on January 25, 2022.  
 
The file shows that $78.60 for the office visit was applied to your deductible. The $71.40 for the skin growth 
destruction was also applied, totaling the $150 to fulfill the deductible. Once that was met, the remaining 
$53.75 was applied as a copayment amount, which is less than the $100 copayment for the surgical services at 
a specialists office. The total for the deductible and copayment is $203.75. Therefore, we decided that the Plan 
does not have to waive the deductible and copayment for a specialist office visit and skin growth destruction 
provided on January 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have waive the $940 copayment for a SNF stay from January 7, 2022, to 
January 31, 2022. 
 
You asked the Plan waive the $940 copayment for a Skilled Nursing Facility stay from January 7, 2022, to 
January 31, 2022. You say that you should not be responsible for this copayment because a COVID-19 
quarantine at the facility led to a longer than anticipated stay. The Plan denied your request. The Plan says you 
must pay $188 per day for days 21-100 for each covered SNF stay. 
 
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 $188 
per day copayment for days 21-100 of Skilled Nursing Facility (SNF) care.  
 
You have been asked to pay a $188 per day copayment for a SNF stay. A SNF stay falls within the Skilled 
Nursing Facility (SNF) Care benefit category. The first twenty days of the SNF stay were from January 7, 
2022, to January 26, 2022. Days 21-25 of the SNF stay were from January 27, 2022, to January 31, 2022.   $188 x 5 days = $940. 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 waive the $940 copayment for a SNF stay from January 7, 
2022, to January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. You say that poking your finger is painful. The Plan 
denied your request. The Plan says the documentation does not support the need for the 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 does not indicate that you use insulin with at least 
three daily injections, or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. 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 continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oncology (prostate) gene expression profile identified 
with code 0005U. 
 You asked the Plan to pre-approve Oncology (prostate) gene expression profile. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the 
requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested testing is only covered when the 
enrollees PSA level is elevated (over 3 ng/ml).  
 
We looked at the file and Medicare rules. Review of the file shows that your PSA level was 2.3 ng/ml and was 
collected on March 26, 2022. In addition, you have a life expectancy of over 10 years. Based on this 
information, we decided that Medicare rules for coverage of Oncology (prostate) gene expression profile have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Oncology (prostate) gene 
expression profile identified with code 0005U.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 Synvisc. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the records provided do not indicate that the 
enrollee has tried and failed the required drugs. The reviewer found that there is no indication that the plan's 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise bike. 
 
You asked the Plan to pre-approve the requested item. You say that you do not have cartilage in one of your 
extremities. The Plan denied your request. The Plan says this equipment is not primarily medical in nature. 
 
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 an exercise bike.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $20 copayment for cardiac rehabilitation services on 
March 25, 2022. 
 
You asked the Plan to waive the $20 copayment for cardiac rehabilitation on March 25, 2022. You say that you 
believed the authorization for this service meant you would not be responsible for a copayment. The Plan 
denied your request. The Plan says you must pay a $20 copayment for Medicare-covered cardiac rehabilitation 
services performed at an office, free standing facility or at a hospital-based provider. 
 
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 
deductible for Cardiac Rehabilitation Services.  
 
You have been asked to pay a $20 deductible for cardiac rehabilitation. Cardiac rehabilitation falls within the 
Cardiac Rehabilitation Services 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 $20 copayment 
for cardiac rehabilitation services on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
December 17, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says 
members must use in-network providers to get medical care and services. The only exceptions are emergencies, 
urgently needed care, when the network is not available, out-of-area dialysis services, and cases in which the 
Plan authorizes use of out-of-network providers 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency transportation (A0427) and ground mileage 
(A0425) provided on September 2, 2020. 
 
You asked the Plan to pay for the emergency transportation and ground mileage. You say that this claim was 
originally filed to the Plan and paid in error. The Plan denied your request. The Plan says this claim was 
received on March 16, 2022, which is past the allowed 12-month timeframe. 
 
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 emergency transportation and ground mileage was not filed until March 
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 emergency transportation (A0427) and 
ground mileage (A0425) provided on September 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy, 30 minutes with patient, (90832) 
provided on August 17, 2021. 
 
You asked the Plan to pay for the outpatient service. You say that the medically necessary service was provided 
to the enrollee in good faith. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the psychotherapy, 30 minutes with patient, (90832) provided 
on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 1, 
2022. 
  You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. 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 March 1, 2022.