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

 
We decided that the Plan has to pay for the physical therapy (PT) services provided on May 4, 2022. 
 
You asked the Plan to pay for the PT services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. while the claims are very similar, they are not exact 
duplicates, as the place of service (POS) 11 is marked on the the claim lines for the new claim. The Plan has 
not provided enough evidence to support whether the new claim is a duplicate or a corrected claim. Based on 
this information, we decided that Medicare rules for coverage of the PT services have been met. Therefore, we 
decided that the Plan has to pay for the physical therapy (PT) services provided on May 4, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for exploration of spinal fusion (CPT code 22830-59-62) 
provided on August 23, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Procedure code 22830-59-62, an 
exploration of spinal fusion is documented in the operative note; however, this procedure is considered 
inclusive to CPT code 22610-62, a single interspace thoracic arthrodesis (with lateral transverse technique, 
when performed), using a posterior or posterolateral technique; therefore, the code cannot be verified. 
Therefore, we decided that the Plan does not have to pay for exploration of spinal fusion (CPT code 22830-59-
62) provided on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G powered orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G powered orthosis. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro Motion G powered orthosis. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the requested robotic orthosis is not proven to be more beneficial for 
treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard 
therapy such as conventional treatments for post-stroke hemiparesis therapy. 
 
 
  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 MyoPro Motion G powered orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a MyoPro Motion G powered orthosis (L8702).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. The Plan denied your request. The Plan says the 
criteria for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
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 a PET scan of the brain. Our reviewer 
says that a PET scan of the brain is not reasonable and necessary at this time. Our physician reviewer found the 
enrollee is not noted to have a diagnosis of AD or FTD, let alone a diagnosis of both conditions. Our reviewer 
also found that this would not meet the basic requirement of the National Coverage Determination (NCD) for 
coverage of this service. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on April 7, 
2022. 
 
You asked the Plan to pay for a digital, binaural hearing aid (V5261). You say that you filed a claim, and it was 
denied. The Plan denied your request. The Plan says the member went to an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by a network hearing or hearing aid provider.  
 
We looked at the file, and the Plan's rules. The record shows that an out-of-network provider was used. Based 
on this information, we decided that the Plan's rules for coverage of a digital, binaural hearing aid (V5261) 
have not been met. Therefore, we decided that the Plan does not have to pay for a digital, binaural hearing aid 
(V5261) provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9366 billed for date of service July 7, 2022, 
through July 13, 2022. 
 
You asked the Plan to pay for procedure code S9366. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9366 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9366 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9366 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9366 billed for date of service July 7, 2022, through July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenomic (PGx) testing provided on May 10, 2022. 
 You asked the Plan to pay for PGx testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says the criteria for coverage of pharmacogenomic 
testing are not met in this case, and therefore this test 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 pay for PGx testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this enrollee has diagnoses of hypertension, anxiety, and depression. Current medications 
include alprazolam, baclofen, citalopram, ibuprofen, lisinopril- hydrochlorothiazide, Symbicort, Ventolin, and 
vitamin D2. There was no specific clinical rationale for the requested laboratory test. This review has 
determined that the enrollee does not meet criteria for PGx testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PGx testing have not been met. Therefore, we decided that the Plan does not 
have to pay for pharmacogenomic (PGx) testing provided on May 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis. 
 
You asked the Plan to pre-approve Restasis. You say that the enrollee needs this. The Plan denied your request. 
The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are 
covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered 
under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99233) provided on May 29, 2022, to 
June 2, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is Subsequent Hospital Care, per day for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medicare decision making of high complexity for service provided. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, records do not show this 
service was of high complexity. There is a more appropriate code to report for service provided. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99233) provided on May 29, 
2022, to June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 99417. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99417 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99417 billed for date of service March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal impacted cerumen requiring instrumentation, 
unilateral (CPT code 69210) provided on April 15, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
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, Medicare payment for code 69210 
is considered to be included in payment for code 92557 and 92567. Therefore, we decided that the Plan does 
not have to pay for removal impacted cerumen requiring instrumentation, unilateral (CPT code 69210) 
provided on April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Procedure code 88361, 
88312, 88305 and 88112 has a physician Fee Schedule PCTC indicator of 1 and the claim a POS of 22 On 
Campus-Outpatient Hospital. The professional interpretation was furnished in the same payment locality from 
where the TC was furnished. We find that the Medicare rule for payment of this claim has not been met as the 
professional interpretation of a diagnostic test must be separately billed with modifier  26 by the interpreting 
physician. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 the intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is experimental, and more research is needed in order to show safety and 
efficacy of the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intracept procedure have not been met. Specifically, this procedure is 
considered experimental, and therefore, not medically necessary. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (64628 and 64629).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for vision care services provided on June 25, 2022. 
 
You asked the Plan to pay for vision care. You say that this was only a routine maintenance service. The Plan 
denied your request. The Plan says that this service is not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit a copy of the appropriate Evidence of Coverage (EOC) 
applicable to this claim. Without this information, we cannot determine whether you have any supplemental 
routine vision benefits that might cover this service. Therefore, the Plan has not shown that its decision to deny 
payment for this service is correct or justified according to your contract with the Plan. Therefore, we decided 
that the Plan has to pay for vision care services provided on June 25, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc augmentation 
(0627T). 
 
You asked the Plan to pre-approve a VIA Disc allograft intervertebral disc augmentation. You say that the 
enrollee has had pain for almost 15 years, and had failed both interventional and conservative treatment. The 
Plan denied your request. The Plan says the clinical value and effectiveness of the VIA Disc allograft 
intervertebral disc augmentation in the setting of discogenic low back pain have not been demonstrated in the 
peer-reviewed literature. 
 
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 a VIA Disc allograft intervertebral disc 
augmentation. Our reviewer says that a VIA Disc allograft intervertebral disc augmentation is not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-
scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the 
noted pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with 
conventional treatment. Our reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer 
also found that the documentation does not support that the VIA disc allograft intervertebral disc augmentation 
is medically reasonable and necessary or safe and effective for the enrollee. 
 
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 VIA Disc allograft intervertebral disc augmentation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc 
augmentation (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee and foot. 
 
You asked the Plan to pre-approve the requested prosthesis. You say that the enrollee is very active. The Plan 
denied your request. The Plan says the request exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses 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 prosthesis. Our physician 
reviewer found that while the enrollee may be a level 3 ambulator, the documentation does not support that the 
enrollee is unable to use a mechanical knee and foot. Furthermore, a review of the Linx system indicates it has 
convenience features which are not medically necessary per Medicare criteria, such as a covered and magnetic 
charging point and a programming app for Android and iOS. The requested Linx system exceeds the enrollees 
medical needs as Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 
 
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 prosthesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee and foot.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 7, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the admission was medically 
necessary. The Plan denied your request. The Plan says an inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee had a successful surgery without complications. An inpatient admission was not 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on June 7, 2022.