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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted with a 
need for oxygen supplementation. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530) and self-care management 
training (97535) provided on February 19, 2021. 
 
You asked the Plan to pay for the therapeutic activities and self-care management training. You say that the 
services provided were medically necessary. The Plan denied your request. The Plan says Medicare denies a 
claim if it is not received by the Plan within 12 months or 1 calendar year from the date when the services were 
rendered. The Plan also says that this claim was received on March 21, 2022, which is past the allowed 12-
month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the therapeutic activities and self-care management training was not filed 
until March 21, 2022. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) 
and self-care management training (97535) provided on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99203) provided 
on December 6, 2021. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you believe you should 
not be charged for this exam. The Plan denied your request. The Plan says you were seen for medical issues 
that you were having with your eyes and not for eyeglass services. The Plan also says that the copayment 
amount you are being charged is correct. 
 
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 
specialist copay for Medicare-covered exams under the Vision care benefit category.  
 
 
 
 You have been asked to pay a $30 specialist copay for the outpatient office visit. This outpatient office visit 
falls within the Medicare-covered exams under the Vision care 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 the outpatient office visit (99203) provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lipiflow Thermal Pulsation System. 
 
You asked the Plan to pre-approve the Lipiflow Thermal Pulsation System. You say that the Lipiflow 
Thermal Pulsation System is medically necessary. The Plan denied your request. The Plan says the Lipiflow 
Thermal Pulsation System is experimental. 
 
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 Lipiflow Thermal Pulsation 
System. Our reviewer says that the Lipiflow Thermal Pulsation System is not considered medically 
reasonable and necessary. Our physician reviewer found that there is insufficient evidence to support that the 
Lipiflow Thermal Pulsation System is medically reasonable and necessary. Additional clinical research is 
required to determine this. 
 
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 Lipiflow Thermal Pulsation System have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Lipiflow Thermal Pulsation System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump. 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Review of the file shows that the item requested is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad 
with pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid 
circulating cold pad with pump.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on April 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that this service was necessary and was billed 
appropriately. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment 
for code 93312. 
 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 93010 
is a column II code to column I code 93312. 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 procedure code 93010 billed for date of service March 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that you were told you had transportation 
benefits. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the Plan does not cover routine transportation. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure from chronic obstructive pulmonary disease. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcutaneous electrical modulation pain reprocessing 
(e.g., scrambler therapy), each treatment session includes placement of electrodes (0278T). 
 
You asked the Plan to pre-approve scrambler therapy. You say that this procedure will address your symptoms 
of chest wall pain. The Plan denied your request. The Plan says there is insufficient evidence regarding the 
clinical value and effectiveness of Scrambler therapy. 
 
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 scrambler therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have a history of lung cancer and chest wall pain. This therapy is considered 
experimental/ investigational. There are other evidence based therapies available to you. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of scrambler therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve transcutaneous electrical modulation pain reprocessing (e.g., scrambler therapy), each 
treatment session includes placement of electrodes (0278T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 18, 2022, billed 
with codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and were billed appropriately. The Plan denied your request. The Plan says this genetic panel was not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 18, 2022, 
billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U and 0033U.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 4, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service March 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex 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 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed to show safety and efficacy. 
 
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 the Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 9, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service February 9, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary. The member's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure, septic shock, urinary tract infection, and urolithiasis. Your medical problems are stable. 
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor kit. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies 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 or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 2 sensor 
kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 
sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve basivertebral nerve (BVN) ablation. 
 
You asked the Plan to pre-approve BVN ablation. You say that basivertebral nerve ablation is medically 
necessary. The Plan denied your request. The Plan says basivertebral nerve ablation 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 BVN ablation. Our reviewer says that 
BVN ablation is not considered medically reasonable and necessary. Our physician reviewer found that at this 
time, this procedure is considered experimental/ investigational. Therefore, the request 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 BVN ablation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BVN ablation.