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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
16, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 16, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to approve in-network coverage for consultation and treatment with an out-of-
network (OON) provider and facility 
 
You asked the Plan to approve in-network coverage for the OON medical services. You say that you feel that it 
is unreasonable for you to need to go two and a half hours away to receive the services you need. You feel that 
the closer provider should be approved. The Plan denied your request. The Plan says that you must you a 
network provider to get in-network coverage. If you wish to use the nearer provider, you may use your OON 
coverage. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home.   
 
The requested providers are out-of-network with your Plan. We were able to confirm that the Plan does not 
have contract providers located within reasonable distance and travel time from your home who can provide 
the requested services. Under Medicare rules, this means that contract providers are not accessible to you. 
Therefore, we decided that the Plan has to approve in-network coverage for consultation and treatment with an 
out-of-network (OON) provider and facility  
 
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 pre-approve lumbar spinal fusion with the Minuteman device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the full-text systematic review suggests no support for using interspinous 
non-pedicle fixation devices for lumbar spinal fusion. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. 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. According to the Food and Drug Administration (FDA), the HA Minuteman G3-R MIS Fusion Plate 
is a posterior, non-pedicle supplemental fixation device, intended for use at a single level in the non-cervical 
spine (T1-S1). The HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft material and is 
not intended for stand-alone use. The documentation does not clearly indicate this is to be used with bone graft 
material. In addition, fusion indications within guidelines/literature for (existing or potential intraoperative) 
instability have not been documented and/or met in this case. In addition, there are multiple alternate pain 
generators plausibly significantly contributing to the clinical condition that have not been fully documented as 
having been excluded and/or ruled out. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
lumbar spinal fusion with the Minuteman device, 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve lumbar spinal fusion with the Minuteman device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing provided on December 12, 2022. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus xF testing provided on December 12, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myrbetriq tablet 50MG. 
 
You asked the Plan to pre-approve myrbetriq tablet 50MG. You say that the enrollee has been tried on 
myrbetriq samples 25mg and 50mg without side effects. The Plan denied your request. The Plan says self-
administered drugs do not fall under Medicare Part B coverage. 
 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 myrbetriq tablet 50MG.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
November 21, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 1, 2020. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program (OTP) facility. The rules say that only an entity enrolled with Medicare as an OTP can bill 
these codes. 
 
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. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for 
medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on November 21, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan, upper arch (D0381) 
and CT scan, lower arch (D0382). 
 
You asked the Plan to pre-approve CT scans of upper and lower arches. You say that this should be covered. 
The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
computed tomography (CT) scan, upper arch (D0381) and CT scan, lower arch (D0382).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Reader and Sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre Reader and Sensor. You say that you do not like 
checking your blood sugar as your fingers get sore and cause pain. The Plan denied your request. The Plan says 
you do not require insulin three or more times daily. 
 
 
 
 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 the FreeStyle 
Libre Reader and Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre Reader and Sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services from January 4, 2022, to January 
9, 2022. 
 You asked the Plan to pay for the services. You say that the claim met 2021 InterQual criteria for inpatient 
admission and reimbursement is requested as billed. The Plan denied your request. The Plan says this facility 
documented no attempt to contact the health plan or the delegated group in a timely manner, the denial is 
upheld. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that there was no 
documentation provided indicating medical necessity for the post stabilization care services  at the non Plan 
facility from January 4, 2022, to January 9, 2022. The enrollee was stable and appropriate for ambulance 
transport with monitoring to a Plan facility for observation/admission. The review has determined that  the 
treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not 
stable for transfer on any dates of 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services from January 4, 2022, to January 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing of 22 or more drug classes (G0483) 
provided on December 6, 2022. 
 
You asked the Plan to pay for definitive drug testing of 22 or more drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that this test is covered when the enrollee meets the 
criteria in the rules section of this letter. 
 
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 definitive drug testing of 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that there 
was no indication for definitive testing in this enrollee. The testing was not medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive drug testing of 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for definitive drug testing of 22 or more drug classes (G0483) 
provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic- porcelain/ceramic for tooth #13 (D6245) and 
retainer crown for tooth #11 (D6792), core buildup (D2950) and gingival irrigation (D4921). 
 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the pontic- porcelain/ceramic and retainer crown has already been 
exhausted and core buildup and gingival irrigation are not covered services. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for pontic- porcelain/ceramic and retainer crown was exhausted. Therefore, we decided that 
the Plan does not have to pre-approve pontic- porcelain/ceramic for tooth #13 (D6245) and retainer crown for 
tooth #11 (D6792), core buildup (D2950) and gingival irrigation (D4921).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on January 5, 2023. 
Additionally, the Plan does not have to waive the copayment for the chiropractic manipulative treatment 
(98940) provided on January 5, 2023. 
 
You asked the Plan to pay for the office visit. Additionally, you asked the Plan to waive the copayment for the 
chiropractic manipulative treatment provided.  
  
 
You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your 
request. The Plan says the office visit is not a covered benefit. Additionally, the copayment has been applied 
correctly to the chiropractic manipulative treatment provided. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for in-network Medicare-covered chiropractic services.  
 
The records show that the office visit at issue is not a covered benefit by Medicare or the Plan. Additionally, 
you were asked to pay a $20 copayment for the chiropractic manipulative treatment provided. 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. Your total liability in this case is  
($38 for the office visit + $20 copayment for the chiropractic manipulative treatment). Therefore, we decided 
that the Plan does not have to pay for the office visit (99202) provided on January 5, 2023. Additionally, the 
Plan does not have to waive the copayment for the chiropractic manipulative treatment (98940) provided on 
January 5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5mg tablets. 
 
You asked the Plan to pre-approve the Eliquis tablets. You say that this is medically necessary. The Plan 
denied your request. The Plan says this drug is self-administered and cannot be covered by 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 Eliquis 5mg tablets.   
Benefits for the Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 37248, 75827) rendered on 
November 3, 2022. 
 
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 that the records do not support the services 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, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 37248: 
 
Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and 
radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial 
vein 
 
CPT 75827: 
 
Venography, caval, superior, with serialography, radiological supervision and interpretation 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation supports coverage 
of the CPT codes in question. CPT 75827 codes for superior vena cava (SVC) venography. There is 
satisfactory documentation that an SVC venogram was performed, demonstrating clot at the cavo-atrial 
junction. In response to this finding, venous balloon angioplasty was performed at the SVC with good result, 
appropriately coded as CPT 37248. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 37248, 75827) rendered on November 3, 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: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 37242) on September 2, 2022. 
 
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 that the records do not support the services 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, the CPT Code Manual definition of 
code 37242 is "Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, 
intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than 
hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, 
arteriovenous fistulas, aneurysms, pseudoaneurysms)." 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation supports that the 
service applicable to CPT code 37242 was rendered. There is satisfactory documentation that the right 
hypogastric artery was canulated and the right internal iliac artery aneurysm was coil embolized with 6 separate 
20mm Nester coils. The documentation also supports that this procedure was appropriate and medically 
necessary. The code used is not a bundled component of any other procedure performed. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 37242) on September 2, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 72-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the enrollee needs 
transportation to dialysis appointments. The Plan denied your request. The Plan says the enrollee has exhuasted 
the transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
72-trip limit.