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

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
approaches to treatment. The Plan denied your request. The Plan says unproven procedures are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis of the lumbar region with neurogenic 
claudication and chronic pain syndrome. The exam reveals a positive straight leg raise bilaterally. There is 
limited flexion and extension. Current evidence based medical guideline and peer reviewed literature do not 
fully support the spinal decompression device procedure over the lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. This enrollee has multiple degrees of spinal stenosis, many not at food and drug administration 
(FDA) indicated levels of moderate spinal stenosis including the planned level of implantation of L3-4.  FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, which have not been 
adequately addressed in the medical records. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Vertiflex interspinous device at L3-4 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there are participating providers available to provide this 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 
a cochlear implant to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these wipes are necessary for your 
condition. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thoracic spine 
and a CT scan of the lumbar spine. 
 
You asked the Plan to pre-approve CT scans of the thoracic spine and lumbar spine. You say that you need 
these scans because you have a few problems with your back and spine. You also say you need the CT scan 
before trying to see if anything you have not tried will help your back. The Plan denied your request. The Plan 
says the criteria was not met for medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scans of the thoracic spine and 
lumbar spine. Our reviewer says that CT scans of the thoracic spine and lumbar spine are not reasonable and 
necessary. Our physician reviewer found there is no specific clinical rationale for the requested CT studies. Our 
reviewer also found that there are no reported neurologic abnormalities on exam, and you have not completed a 
trial of conservative therapy such as physical therapy or chiropractic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans of the thoracic spine and lumbar spine have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thoracic spine 
and a CT scan of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on May 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug services provided from March 7, 
2022, to March 31, 2022. 
 
You asked the Plan to waive the coinsurance for the drug services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says this cost sharing was charged correctly as 
you did not meet your maximum out-of-pocket amount until this claim at issue. 
 
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% 
coinsurance for Medicare Part B prescription drugs.   
You have been asked to pay less than a 20% coinsurance for the drug services as this was the remainder of your 
out-of-pocket maximum amount for the 2022 benefit year. This item/service falls within the Medicare Part B 
prescription drugs 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 coinsurance for the drug services 
provided from March 7, 2022, to March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for evaluation and management of a new 
patient (92205) provided on March 8, 2022. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
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 99205 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99205 is not supported in the record. Specifically, the documentation submitted 
indicates that this enrollee previously received professional services from a physician within the same 
physician group practice, with the same physician specialty. Based on this information, we decided that 
Medicare rules for coverage of the domiciliary visit have not been met. Therefore, we decided that the Plan 
does not have to pay for the office visit for evaluation and management of a new patient (92205) provided on 
March 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (76942) provided on January 4, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 76942 is not supported in the medical record. Specifically, this service has professional 
component / technical component indicator of 1. The claim was billed with place of service 22, outpatient 
hospital. The professional interpretation of the diagnostic test must be separately billed with modifier 26 by the 
interpreting physician.  
 
 
 
 
 
  
Based on this information, we decided that Medicare rules for coverage of the radiology services have not been 
met. Therefore, we decided that the Plan does not have to pay for radiology services (76942) provided on 
January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says that that the coverage criteria 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee has active comorbidities that would require close 
medical monitoring on an inpatient basis during rehabilitation and hip fracture is an IRF compliant diagnosis. 
The evaluating physical and occupational therapists recommend intense therapy thus IRF criteria have been 
met and is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of head or brain (70450) 
provided on May 17, 2022. 
 
You asked the Plan to pay for the CT. You say that the enrollee's insurance should cover a fall at home as 
stated on page 68 of the coverage book. The Plan denied your request. The Plan says the enrollees claim 
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the 
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) of head or brain (70450) 
provided on May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical treatment of varicose veins. 
 
You asked the Plan to pre-approve surgical treatment of varicose veins. You say that the requested services are 
a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested services are 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 surgical treatment of varicose veins. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that while there is satisfactory documentation of symptoms, it is not clear that you have failed conservative therapy. You have apparently been prescribed compression stockings, but 
there is no documentation that you have used them regularly for a 3-month period nor is there documentation 
of your response to their use. There is also no assessment wherein a surgical treatment plan is articulated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical treatment of varicose veins have not been met. Therefore, we decided 
that the Plan does not have to pre-approve surgical treatment of varicose veins.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 1, 2021. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue were billed correctly. The 
Plan denied your request. The Plan says rules for payment for diagnostic services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the professional interpretation of a diagnostic test 
must be separately billed with modifier -26 by the interpreting physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the case record supports that modifier -26 is required to be reported on the claims at issue. The claims were not billed with this modifier. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on December 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on April 1, 
2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says a licensed professional counselor is not 
eligible to enroll in Medicare per Medicare coverage rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a licensed professional counselor is on the list of 
individuals who are not eligible to enroll in Medicare 
 
We looked at the file and Medicare rules. In this case, the services in question have been rendered by a licensed 
professional counselor. Based on this information, we decided that Medicare rules for coverage of the 
psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the 
psychotherapy services (90837) provided on April 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seventy (70) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have upcoming 
appointments and need additional trips for your transportation. The Plan denied your request. The Plan says the 
request exceeds your benefit limit. 
 
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.  
 
We looked at your request, the records in the case file, and the rules. The 49th trip and beyond is not a covered 
benefit. Your 2022 EOC says up to forty-eight (48) one-way trips are covered each year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve seventy (70) additional 
routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left custom foot orthotic (L3010). 
 
You asked the Plan to pre-approve the foot orthotic. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease. Additionally, the left foot orthotic requested 
will not be for a shoe that is an integral part of a covered brace. Although a foot orthotic may be appropriate for 
you, neither Medicare nor the Plan provides coverage of a foot orthotic for your condition. Therefore, we 
decided that the Plan does not have to pre-approve a left custom foot orthotic (L3010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on May 24, 2022, by an OON 
provider. 
 
You asked the Plan to pay for outpatient surgery. You say that we feel this procedure meets medical necessity 
and kindly ask for reconsideration of payment for the services we provided for your member. The Plan denied 
your request. The Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient surgery provided on May 24, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical equipment (L1940, L2820, L2275, L2230, & 
L2280) provided July 1, 2021. 
 
You asked the Plan to pay for the medical equipment. You say that these items were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain a valid proof of delivery. There is no itemized shipping invoice showing what 
items were delivered. The date of service billed does not match the date the items were provided (August 23, 
2021). The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for medical equipment (L1940, L2820, 
L2275, L2230, & L2280) provided July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is a good candidate for these 
services. The Plan denied your request. The Plan says that this service is considered experimental and 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex device for the enrollee.