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

 
We decided that the Plan does not have to pre-approve an MRI of the lower spine. 
 
You asked the Plan to pre-approve an MRI of the lower spine. You say that an MRI is medically necessary. 
The Plan denied your request. The Plan says an MRI of the lower spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lower spine. Our 
reviewer says that an MRI of the lower spine is not medically necessary. Our physician reviewer found the 
neurological exam is negative, no red flags. Your last x-rays were in 2019 with no formal report. No supervised 
physical therapy program has been attempted nor documented. In light of all this, the medical necessity of MRI 
of the lumbar spine has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower spine. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lower spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2782, V2781, V2304, V2702, 
V2100, V2750) provided on January 26, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you were not aware that you had a coverage limit of 
$200 for these services. The Plan denied your request. The Plan says this claim was processed in accordance 
with your benefits. The total cost of the eyeglasses was $480.75. The Plan paid the full $200 benefit allowance, 
and you are responsible for the remaining cost. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $200 per calendar year. 
 
We looked at the file and the Plan's rules. The documentation shows that the Plan has paid the full $200 
allowance for these services, and you are being asked to pay only the amount that exceeds this allowance. 
Based on this information, we decided that you have been asked to pay the correct amount for these eyeglasses 
based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay any additional 
amount for the eyeglasses (V2020, V2782, V2781, V2304, V2702, V2100, V2750) provided on January 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service November 3, 2021. 
 
You asked the Plan to pay for the lab testing as billed. You say that the services were medically necessary and 
should be paid. The Plan denied your request. The Plan says the records do not support the billed date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab testing claims, the date of service should 
be reported as the date that the sample was collected. 
 
We looked at the file and Medicare rules. The file shows that the sample was collected on November 2, 2021, 
which does not support the date of service of November 3, 2021. Based on this information, we decided that 
Medicare rules for coverage of the lab testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab testing billed for date of service November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on November 1, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you contacted the Plan and were told you had 
coverage. The Plan denied your request. The Plan says the hearing aids you purchased are not the Plan's 
hearing aid brand. The Plan also says that there was no misinformation or a misquote given by the Plan's 
Customer Service Center prior to the services being rendered. 
 
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 the hearing aids are the Plan's approved hearing aid brand.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids provided on November 1, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography, heart, without contrast material, with 
quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve computed tomography, heart, without contrast material, with quantitative 
evaluation of coronary calcium. You say that computed tomography, heart, without contrast material, with 
quantitative evaluation of coronary calcium is medically necessary. The Plan denied your request. The Plan 
says that computed tomography, heart, without contrast material, with quantitative evaluation of coronary 
calcium does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 computed tomography, heart, without 
contrast material, with quantitative evaluation of coronary calcium. Our reviewer says that computed 
tomography, heart, without contrast material, with quantitative evaluation of coronary calcium is medically 
necessary. Our physician reviewer found that the enrollee has atherosclerotic plaque in the carotid arteries by 
ultrasound. Importantly, he has been unable to tolerate standard Statin therapy due to myalgias. For this reason 
it is important to stratify risk in this enrollee that needs medication for hyperlipidemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 
(75571).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultra-lightweight wheelchair and associated 
options/accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that please reconsider the documentation provided 
for this K0005 manual wheelchair and components. The enrollee requires this level of equipment to meet her 
current medical, functional, mobility needs. The Plan denied your request. The Plan says the ultralight manual 
wheelchair and requested options/accessories are not medically necessary and cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested ultra-lightweight manual wheelchair exceeds the enrollees medical needs. The 
documentation notes that the enrollee can independently propel a lightweight manual wheelchair. There is no 
objective exam of the shoulder that indicates that the enrollee has a right shoulder injury as the occupational 
therapy note claims, or that she cannot propel the lightweight manual wheelchair over 20 feet. There are no 
extenuating factors that would require a K0005 wheelchair to move on gravel, pavement and grass (in addition 
to carpet). The requested K0005 is not medically necessary per L33788 and the Social Security Act, Section 
1862 (a)1(A) and the 42 CFR 411.15(k) as there is insufficient evidence in the literature of effectiveness for 
this enrollees condition.   
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultra-lightweight wheelchair and associated options/accessories.
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 this admission is medically necessary. The Plan 
denied your request. The Plan says the criteria for an IRF has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs.  There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the glasses provided on January 1, 2022. 
 
You asked the Plan to pay in full for the glasses. You say that you would like this claim to be considered for 
full payment under the current time period. The Plan denied your request. The Plan says you have exceeded 
your benefit limit.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan pays up to $160 for eyeglasses every 12 months. 
 
We looked at the file and the Plan's rules. The contract says that the Plan pays up to $160 for eyeglasses every 
12 months. The record shows that between the February 17, 2021, November 15, 2021, and January 1, 2022 
dates of service, you reached the maximum allowable for eyeglasses while processing this claim for the 
January 1, 2022 date of service, and your annual maximum benefit for eyeglasses has been exhausted. Based 
on this information, we decided that the Plan's rules for coverage of the glasses have not been met. Therefore, 
we decided that the Plan does not have to pay in full for the glasses provided on January 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 31, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
 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. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal injection provided on November 15, 2021. 
 
You asked the Plan to pay for the spinal injection. You say that this was denied using epidural injection rules, 
and the injection provided is subarachnoid. This treatment was necessary for the enrollee's condition. The Plan 
denied your request. The Plan says the records provided do not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the spinal injection have not been met. Specifically, the documentation submitted does not include 
a valid signature from the persons responsible for the care of the beneficiary. Review of the progress note shows that the field for electronic signature is blank, and the only potential signature is typed and undated. In 
addition, the progress note does not have a date of service specified, meaning it cannot be confirmed that this 
note is for the services provided on the date of service at issue. Therefore, we decided that the Plan does not 
have to pay for the spinal injection provided on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on October 27, 2021. 
 
You asked the Plan to pay for the testing services. You say that this test is more reliable and objective than 
other urine-based detection tests. The Plan denied your request. The Plan says the testing is not covered. 
 
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 the testing services. Our physician reviewer 
found that the enrollee has microscopic hematuria and benign prostatic hyperplasia (BPH). There is no history 
of urothelial cancer. A computed tomography (CT) scan revealed possible bladder stones. The records do not 
show that CxBladder testing would impact clinical management to improve his outcome. Cystoscopy, 
ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of 
Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in those 
with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and 
low-grade tumors. Therefore, the records do not show that CxBladder testing was medically reasonable and 
necessary to treat 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 the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder testing provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the methadone medication assisted treatment (G2067) 
provided on March 28, 2021. 
 
You asked the Plan to pay for the methadone medication assisted treatment. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider does 
not appear on the Opioid Treatment Program Providers list maintained by CMS. 
 
The Plan must follow Medicare rules. Medicare rules say that an OTP must be enrolled under section 1866(j) 
of the Act; have in effect a certification by the Substance Abuse and Mental Health Services Administration 
(SAMHSA) for such a program; must be accredited by an accrediting body approved by SAMHSA; and meets 
such additional conditions as the Secretary may find necessary to ensure the health and safety of individuals 
being furnished services under such program and the effective and efficient furnishing of such services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the methadone medication assisted treatment have not been met. Specifically, this provider does 
not appear on the Centers for Medicare and Medicaid Services Opioid Treatment Program Providers dataset. 
Therefore, we decided that the Plan does not have to pay for the methadone medication assisted treatment 
(G2067) provided on March 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a femur or knee, patellofemoral arthroplasty procedure 
(27599). 
 
You asked the Plan to pre-approve a patellofemoral arthroplasty procedure. You say that the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure does 
not meet criteria. 
 
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 patellofemoral arthroplasty procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of 
recent, reasonable, and comprehensive less invasive conservative care measures. The documentation does not 
indicate a trial and failure of physical therapy. Additionally, the enrollee is noted to have had improvement 
with the brace and cortisone injection. Moreover, the imaging does not corroborate significant arthritic 
pathology in the patellofemoral space of the right knee. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical 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 patellofemoral arthroplasty procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a femur or knee, patellofemoral arthroplasty procedure (27599).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion or replacement of neurostimulator system 
for treatment of central sleep apnea; complete system (trans venous placement of right or left stimulation lead, 
sensing lead, implantable pulse generator) (0424T). 
 
You asked the Plan to pre-approve an insertion or replacement of a neurostimulator system. You say that the 
requested procedure is medically necessary. The Plan denied your request. The Plan says the requested 
procedure does not meet criteria. 
 
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 an insertion or replacement of a 
neurostimulator system. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this is an implantable neurostimulator, 
utilizing a transvenous lead similar to a cardiac pacemaker, of the phrenic nerve with the aim stabilizing the 
breathing pattern and restoring sleep throughout the night for patients with CSA. It was approved by the FDA 
in 2017. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of the Remede implantable nerve stimulator in patient management. As 
a result, at this time the Remede system would not be considered medically appropriate and necessary in your 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an insertion or replacement of a neurostimulator system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an insertion or replacement of 
neurostimulator system for treatment of central sleep apnea; complete system (trans venous placement of right 
or left stimulation lead, sensing lead, implantable pulse generator) (0424T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (CPT code(s): 95886-26 X2) and 
nerve conduction studies (CPT code 95910-26) provided on November 22, 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 services are not supported by the records. 
 
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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure) and 95910 is nerve conduction studies; 7-8 studies. We 
asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan 
was correct in denying the request to pay for the services. Our reviewer found the review has determined that 
the services were not supported in the medical records provided for review.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for needle electromyography (CPT code(s): 95886-26 X2) and nerve conduction studies (CPT code 
95910-26) provided on November 22, 2021.