Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH 
admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was admitted with a HeartMate 3 left ventricular assist device drive 
line infection. The record indicates that the enrollee has unresolved medical conditions and requires ongoing 
acute care services. The medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental reconstruction services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. 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 pre-approve 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 pre-approve dental reconstruction 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles (K0108) and a power seat elevator 
(E2300) for a power wheelchair. 
 
You asked the Plan to pre-approve the push handles and power seat elevator. You say that these items are 
medically necessary. The Plan denied your request. The Plan says the requested accessories are not primarily 
medical in nature and are non-covered. 
 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 push handles (K0108) and a power seat elevator (E2300) for 
a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayment for spinal fusion surgery and 
physical therapy (PT) services provided from October 20, 2021, to October 21, 2021. 
 
You asked the Plan to waive the coinsurance and copayment for the fusion surgery and PT services. You say 
that you feel that the services should be covered at the in-network rate. The Plan denied your request. The Plan 
says the correct copayment and coinsurance was applied. 
 
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 25% 
coinsurance for surgery or other services provided at an outpatient hospital.   
You have been asked to pay $3,393.64 for the fusion surgery, which is 25% of the allowed amount ($13,574.56 
allowed amount x 25% coinsurance = $3,393.64). The fusion surgery falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. You have also been asked to pay a $25 copayment for the PT services. The PT services fall within the 
Outpatient Rehabilitation Services benefit category. Please note that both were processed at the in-network 
rate. 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 coinsurance and copayment for spinal fusion surgery and physical 
therapy (PT) services provided from October 20, 2021, to October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (51785, 95870) provided on April 28, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 51785 is "Needle electromyography studies (EMG) of 
anal or urethral sphincter, any technique". 
 
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 says that the use of code 51785 is 
not supported by the records provided. Our reviewer found that the documentation includes "Needle (ENG) 
Bilateral: Subdermal needle electrode were placed in the corresponding myotomes in relation to the operative 
levels bilaterally, and no spontaneous electromyographic (EMG) activity was observed at baselines." "Anal 
Sphincter Electromyography (ENG): Subdermal electrode were placed in the anal sphincter to monitor 
electromyographic (EMG) responses during the procedure." The documentation is insufficient to support the 
use of code 51785. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 51785 have not been met. 
 
In this case, we have confirmed that code 9587 0is a column II code to column I code 95861. 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 services (51785, 
95870) provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit (99214) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the records received do not indicate that the enrollee has 
an emergent or urgent medical condition, or is in need of specialized services that are not available in the 
network. The Plan also says that there are in-network providers within a reasonable distance from the enrollee's 
location that can provide this service or item. 
 
 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit (99214) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abilify Main, 400mg injection. 
 
You asked the Plan to pre-approve Abilify Main, 400mg injection. The Plan denied your request. The Plan says 
non-injectable, self-administered drugs are covered by the pharmacy benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Abilify Main, 400mg injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that you would like to see an out-of-
network provider because of the location of the in-network provider. The Plan denied your request. The Plan 
says services has already been approved for an in-network provider that the enrollee has seen. There is also no 
valid reason why the enrollee cannot continue to see the in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage of a primary care physician (PCP) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve coverage of the PCP. You say that you would like to see this provider for an 
existing condition. The Plan denied your request. The Plan says the PCP the enrollee is requesting to see is an 
out-of-network provider. There are in-network PCP that provide the same quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
coverage of a primary care physician (PCP) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding significant Modic changes on magnetic 
resonance imaging (MRI). The MRI addendum dated 11/18/21 states possible subtle type II Modic changes at 
the L5-S1 level. In this case, there were/are multiple plausible pathologic sources of significant pain 
generation. There are noted decreased reflexes and sensation in the bilateral lower extremities. Additionally, 
detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting.  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 request for Intracept procedure at L4, L5, and S1 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from June 22, 2021, through 
August 12, 2021. 
 
You asked the Plan to pay for acupuncture services. The Plan denied your request. The Plan says there was no 
referral on file for acupuncture treatment rendered on June 22, 2021. Additionally, the request for acupuncture 
treatment rendered July 20, 2021, and August 12, 2021 exceeds the benefit limit under your Wellness 
Allowance. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file, the Medicare rules and the Plans rules. The file shows that there was no referral on file 
for acupuncture treatment rendered on June 22, 2021. Additionally, the request for acupuncture treatment 
rendered July 20, 2021, and August 12, 2021 exceeds the benefit limit under your Wellness Allowance.  
Therefore, we decided that the Plan does not have to pay for acupuncture services provided from  
June 22, 2021, through August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that you disagree with the decision as 
attached is all the clinicals needed to support as to why the enrollee needed the medical equipment. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have been wearing stockings 
since 2015. Without the stockings your legs swell and you are very vulnerable to getting these wounds. The 
Plan denied your request. The Plan says the requested item is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6549.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve conduction study provided on July 
16, 2021. 
 
You asked the Plan to waive the copayment for a nerve conduction study. You say that you are on a budget and 
this $30 copayment is a lot for you to pay. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $30 
copayment for outpatient diagnostic tests, not otherwise specified in the Evidence of Coverage.  
 
 You have been asked to pay a $30 copayment for a nerve conduction study. A nerve conduction study falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a nerve conduction study provided on July 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of stabilization device (22867). 
 
You asked the Plan to pre-approve insertion of stabilization device (22867). You say that she has a handicap 
child that she is responsible for, and this will help the member heal faster. The Plan denied your request. The 
Plan says experimental and investigational devices are 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 pre-approve insertion of stabilization device 
(22867). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that 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 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of stabilization device (22867) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion of stabilization device (22867).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for continuous 
glucose monitors have not been met. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor (K0554).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a(n) magnetic resonance imaging (MRI) of 
the brain stem provided on September 13, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that your plan is a PPO and the service 
should be covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $225 
copayment for diagnostic and nuclear medicine radiological services, including MRI's.  
 
You have been asked to pay a $225 copayment for the MRI. The MRI falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a(n) magnetic resonance imaging (MRI) of the brain stem provided on September 13, 2021.