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

 
We decided that the Plan does not have to pre-approve for the Coflex procedure. 
 
You asked the Plan to pre-approve for the Coflex procedure. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary due to insufficient evidence of efficacy. 
 
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 for the Coflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you are a 75-year-old male enrollee being treated for other intervertebral disc 
displacement, lumbar region. Current evidence based medical guideline and peer reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy.  
 
 
 
 There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition as discussed above. Food and Drug Administration (FDA) indications state 
that the Coflex device is for use in one- or two-level lumbar stenosis from L1- L5 in skeletally mature patients 
with at least moderate impairment in function, who experience relief in flexion from their symptoms of 
leg/buttocks/ groin pain, with or without back pain, and who have undergone at least 6 months of non-operative 
treatment. FDA contraindications include prior fusion or decompressive laminectomy, radiographically 
compromised vertebral bodies, severe facet hypertrophy, spinal instability, scoliosis, obesity, and osteoporosis, 
and which have not been adequately addressed in the medical records. There is imaging evidence of 24 degrees 
of lower thoracic and upper lumbar spine dextroscoliosis centered at L3. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the requested Coflex procedure at levels L3-L4, 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 for the Coflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve for the Coflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ESI is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain 
that is constant and rated at five out of 10. She has been treated with medical therapy, physical therapy, aqua-
therapy, chiropractic care, TENS unit, and transforaminal epidural steroid injections (TFESIs) at L5-S1. There 
is no documentation of disc herniation, osteophyte or osteophyte complexes, or severe degenerative disc 
disease producing foraminal or central spinal stenosis. The criteria for coverage are not met and the services are 
not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 4, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on March 4, 2021.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization was denied because the IRF is not medically necessary and the 
enrollee's care needs can continue to be met in the skilled nursing facility 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable ramp provided on September 17, 2021. 
 
You asked the Plan to pay for the ramp. You say that the ramp was necessary because you could not get out of 
the house. The Plan denied your request. The Plan says the item is not a covered device. 
 
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 pay for the portable ramp provided on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be 
submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided on October 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 9, 2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is no 
documentation how the results of this testing would affect the enrollee's medical care. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on July 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee is not on insulin. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography, head or brain (70450) provided 
on October 28, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic services. You say that you have provided a clinical summary for 
substantiation of medical necessity that supports the need for the services provided and billed. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 computed tomography, head or brain (70450) 
provided on October 28, 2020 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and was at a moderate to maximal assist level with transfers. There are no identifiable skilled nursing 
service needs and skilled therapy service needs. You do not require skilled nursing or therapy services on a 
daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on September 24, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing facilitates the early detection of 
bladder cancer. The Plan denied your request. The Plan says this service does not meet Medicare's criteria of 
being medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there is insufficient information in the record to 
determine if Medicare rules for coverage of the testing have been met. Specifically, there are no medical 
records to show that the testing was ordered based on signs and/or symptoms. Medicare does not cover this 
testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the CxBladder 
testing provided on September 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography, head (70544) provided 
November 10, 2021. 
 You asked the Plan to pay for the diagnostic service. You say that the medical records provided support the 
necessity of the service in dispute. The Plan denied your request. The Plan says this code is 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 CPT code. In this case, we have confirmed that code 70544 
is a column II code to column I code 70551. 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 the magnetic resonance angiography, head (70544) provided 
November 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable and improving but still requires additional short-term acute care services that can 
safely be administered at the current facility.  The patient does not require services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that the patient requires that are not already available and covered at the current 
facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental telehealth visit you had on September 7, 2021. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental telehealth visit you 
had on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Axolotl Ambient/Cryo injections described by code 
Q4215. 
 
You asked the Plan to pre-approve the requested injections. You say that you feel that this should be covered. 
The Plan denied your request. The Plan says there is not sufficient literature to support the use of this agent for 
your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested injections. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has arthritis of the knee. The requested service is 
not the service documented in the notes that is to be performed. The record document treatment with 
Protext/Wharton's jelly while the request is Axolotl Ambient or Cryo, per the requested code. Notwithstanding 
this discrepancy, the requested service has not been shown to be safe and efficacious for the enrollee's clinical 
condition, as defined by Medicare rules. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
 
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 injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Axolotl Ambient/Cryo injections described by code Q4215.