Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network (OON) provider at in-network rates. 
 
You asked the Plan to pre-approve a pneumatic compression device to be provided by an OON provider at in-
network rates. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
the requested item can be provided by a 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 
a pneumatic compression device to be provided by an out-of-network (OON) provider at in-network rates.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you fully meet the Medicare criteria for 
LTACH services. The Plan denied your request. The Plan says the documentation received shows that the 
enrollee does not meet the guidelines for LTACH services, and they can receive the care they need in another 
setting like a skilled nursing facility. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder (ILR). You say that the requested service is 
medically necessary. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the implantable loop recorder (ILR). 
Our reviewer says that the requested ILR is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that the enrollee has atrial fibrillation. The 
reviewer found that there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. Therefore, the reviewer found there is 
insufficient documentation to support the medical necessity for insertion of an ILR in the enrollees 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 the implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, including 
programming (33285).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended polysomnography (95811). 
 You asked the Plan to pre-approve an attended polysomnography. You say that an in-lab study is medically 
necessary to address the enrollee's sleep apnea, and re-establish on PAP therapy. The Plan denied your request. 
The Plan says this request does not meet medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat PSG or PSG with CPAP titration may be 
indicated in the following circumstances listed in the Medicare 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 pre-approve an attended polysomnography. Our 
reviewer says that an attended sleep study is not medically necessary. Our physician reviewer found the 
enrollee has a history of OSA and wishes to restart CPAP. The suspicion for OSA is very high based on current 
symptoms and history of confirmed OSA, and there is no suspicion of other sleep disorders. Our reviewer 
found that there are no conditions that would require an attended PSG, such as severe lung or heart disease.  
Our physician reviewer also found that a home polysomnography would be 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 an attended polysomnography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an attended polysomnography (95811).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc procedure. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is an experimental/investigational method. Therefore, the requested procedure is 
deemed 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 VIA Disc procedure.
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 April 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim has QK modifier indicating this 
portion was for the anesthesiologist. You say that the anesthesia records are attached, and the claim should be 
reprocessed for payment. The Plan denied your request. The Plan says procedure code 00914 has been paid. 
The Plan also 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 April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine-transportation mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that the requested additional mileage is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for routine 
transportation have not been met. 
 
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 one-way trips that do not exceed 50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. Specifically, you have requested 
trips that would exceed 50 miles of driving distance. Therefore, we decided that the Plan does not have to pre-
approve additional routine-transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from October 2, 2021, to 
December 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the plan should cover the charges for the 
services you received. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advanced. 
 
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 chiropractic services provided from October 2, 
2021, to December 28, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on , by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that you have never been properly diagnosed. 
You also say you do not remember anything and cannot care for yourself. The Plan denied your request. The 
Plan says they are able to safely refer you to an 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 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 a specialist office visit provided on , by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility services (procedure code 99306) provided to 
the enrollee on December 1, 2020. 
 
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 the place of service is incorrect. 
 
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 99306 is "initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit." 
 
We find that CPT code 99306 is not supported in the medical record. Specifically, it appears that the enrollee was not receiving skilled nursing facility services on this date. The billed place of service - 31 - is incorrect, as 
it is for inpatient skilled nursing. 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 nursing facility 
services (procedure code 99306) provided to the enrollee on December 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that this is for continuation of treatment. You also 
say that if it is not approved, the enrollee may end up in the emergency room. The Plan denied your request. 
The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are 
covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered 
under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Additionally, the record indicates that the requested drug is not being used for cancer. 
Therefore, we decided that the Plan does not have to pre-approve Methotrexate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481.  
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, we have confirmed that code 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 83789 billed for date of service March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit and laboratory service provided on April 4, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visit and laboratory service. You say that you were assured your PCP 
would remain the same and services would be covered under your Plan. The Plan denied your request. The 
Plan says the services were provided out-of-network and were not approved in advanced. 
 
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 office visit and laboratory service provided on 
April 4, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is too complex for skilled 
nursing care and should transfer to a long-term acute care setting as she requires extended and acute-care level 
interventions provided by complex care trained staff, interdisciplinary treatment, and team driven rehabilitation 
to resume reconditioning and improvement. The Plan denied your request. The Plan says this is not medically 
necessary, and continued acute hospital stay was offered, until the member could discharge to a lower level of 
care. 
 
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 the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre (continuous glucose monitor) CGM 
and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our reviewer 
says that the requested CGM and supplies are not medically reasonable and necessary. Our physician reviewer 
found that the documentation does not show that the enrollee is insulin-treated with three or more daily 
injections of insulin or using a Medicare-covered continuous subcutaneous insulin infusion pump. The enrollee is not on insulin based on the records provided, she is only on Ozempic. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre (continuous glucose monitor) CGM and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outlier costs for inpatient services provided on May 8, 
2021, through May 21, 2021. 
 
You asked the Plan to pay for the outlier costs. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an itemized bill was requested and not 
received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outlier costs for inpatient services 
provided on May 8, 2021, through May 21, 2021. have been met. Specifically, the documentation submitted 
does not include an itemized bill or complete medical records. The record shows that the Plan requested this 
information without response. We are unable to determine if the outlier costs billed on the inpatient claim are 
supported.. Therefore, we decided that the Plan does not have to pay for the outlier costs for inpatient services 
provided on May 8, 2021, through May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Allograft. 
 
You asked the Plan to pre-approve Allograft. You say that the enrollee is not able to move without pain. You 
say that the requested treatment will help the enrollee heal faster. The Plan denied your request. The Plan says 
the requested treatment is unproven and 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 Allograft. Our reviewer says that 
Allograft services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an 
effective and/or safe treatment for the noted pathology.  The requested VivaGen has not been proven and 
further testing is needed to consider this type of allograft. Additionally, the Infuse bone morphogenetic protein 
(BMP) is not supported in large-scale, long-term peer-reviewed literature in posterior lumbar fusions. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested fusion enhancer product VivaGen and Metronic Infuse BMP 
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 Allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Allograft.