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

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760). 
 
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that the requested stimulator 
is medically necessary. The Plan denied your request. The Plan says the requested stimulator does not meet 
criteria. 
 
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 an ultrasonic osteogenesis stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found detailed documentation is not evident regarding serial x-rays that are 
90 days apart demonstrating a nonunion. The x-rays were noted from 5/24/22 and 6/9/22. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 
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 ultrasonic osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a nuclear medicine study of the heart muscle 
and contrast agent (code Q9969) provided on January 12, 2022. 
 
You asked the Plan to waive the cost share for nuclear medicine study and contrast agent. You say that you 
assumed this provider was in-network. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% 
coinsurance for out-of-network diagnostic radiology and complex imaging service. The contract also says there 
is a $490 combined annual deductible which applies to certain items and services. The Plan deductible applies 
to out-of-network diagnostic radiology and complex imaging services. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $717.44 for a nuclear medicine study. The deductible was not met at the time of service; therefore, 
$437.39 was applied to satisfy the remainder of the deductible. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $490 deductible which applies to diagnostic radiology and 
complex imaging services. This cost sharing is a contractual obligation that had not been met at the time the 
nuclear medicine study was performed on January 12, 2022.  
 
The allowed amount remaining after you paid your deductible is $933.50 ($1,370.89 original allowed amount - 
$437.39 deductible paid = $933.50 remaining allowed amount). You have been asked to pay $280.05, which is 
30% of the remaining allowed amount for the nuclear medicine study ($933.50 remaining allowed amount x 
30% coinsurance = $280.05). You have also been asked to pay $3, which is 30% coinsurance of the allowed 
amount for the contrast agent (code Q9969) ($10 allowed amount x 30% coinsurance = $3). You have been 
asked to pay a total of $720.44 ($437.39 deductible + $280.05 coinsurance + $3 coinsurance = $720.44). The 
nuclear medicine study and contrast agent falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. 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 cost share for a nuclear 
medicine study of the heart muscle and contrast agent (code Q9969) provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Exogen bone stimulator (E0760). 
 
You asked the Plan to pre-approve an Exogen bone stimulator. You say that the requested stimulator is 
medically necessary. The Plan denied your request. The Plan says the requested stimulator does not meet 
criteria. 
 
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 an Exogen Bone Stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided records do not document non-union of the fracture for at least 90 
days as is the generally accepted standard of care for use of bone growth stimulators for such fractures. 
 
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 Exogen bone stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Exogen bone stimulator (E0760).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you receive the specimens from the 
referring provider and the referring provider is in-network with the Plan. The Plan denied your request. The 
Plan says the rendering and referring providers are both OON providers and there was no approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 the laboratory services provided on April 20, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first two vertebral bodies lumbar or sacral (64628) and destruction by 
neurolytic agent (64629). 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve, including all 
imaging guidance; first two vertebral bodies lumbar or sacral and destruction by neurolytic agent. The Plan 
denied your request. The Plan says Medicare does not cover unproven and not medically necessary procedures 
due to insufficient evidence of efficacy. More studies are needed to show the intracept procedure is safe and 
effective. 
 
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 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral and destruction 
by neurolytic agent. Our reviewer says that the intracept procedure is not medically necessary. Our physician 
reviewer found that the intracept procedure remains experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first two vertebral bodies lumbar or sacral and destruction by neurolytic agent have not been met. 
Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral (64628) and 
destruction by neurolytic agent (64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an ocrelizumab injection provided on 
August 25, 2021, and September 8, 2021. 
 
You asked the Plan to reduce the cost share for an injection. You say that you were told you only had a $45 
copayment for these injections. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs.  
 
The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay $2,569.49, which is 20% coinsurance of the allowed amount for each injection on August 25, 2021, and September 8, 2021 ($12,847.47 allowed amount x 20% coinsurance = $2,569.49). You have been asked to pay 
a total of $5,138.98 ($2,569.49 coinsurance x 2 injections = $5,138.98). An injection 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 reduce the cost share for an 
ocrelizumab injection provided on August 25, 2021, and September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode 
array, epidural (63650) and implantable neurostimulator electrode (L8680). 
 
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 your records show you have not had therapy, surgical treatment or 
that you are not a surgical candidate. 
 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. Spinal cord 
stimulator trial is limited to patients with an evidence based indication and who have exhausted alternatives, 
and this would be a late or last resort. This is not the case here. Our physician reviewer found that your 
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 Percutaneous implantation of neurostimulator electrode array, epidural (63650) and 
implantable neurostimulator electrode (L8680).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from October 18, 2021, through November 15, 2021.
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says a Medicare plan may not pay for services given by a physician or other practitioner who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from October 18, 2021, through November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an interspinous spacer at L3-L4. 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this should be approved as 
this has been helpful for many other patients with your condition. The Plan denied your request. The Plan says 
there is not enough evidence to support the medical necessity of this type of procedure. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found interspinous spacers are experimental. More research is needed. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve placement of an interspinous spacer at L3-L4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness exam provided on April 4, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an annual wellness exam. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advance. 
 
 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 annual wellness exam provided on April 4, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoulder arthroscopy procedure.
You asked the Plan to pre-approve the shoulder arthroscopy. You say that you feel that these procedures are medically necessary. The Plan denied your request. The Plan says the records do not support the need for arthroscopic surgery at this time.
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 shoulder arthroscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the injection should be performed prior to arthroscopic procedures. There is no need for arthroscopy surgery for shoulder pain.
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 shoulder arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a shoulder arthroscopy procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gocovri. 
 
You asked the Plan to pre-approve Gocovri. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Gocovri.  
 
Benefits for Gocovri 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the freeing of bowel adhesion (44005) provided on March 
28, 2021. 
 
You asked the Plan to pay for the freeing of bowel adhesion (44005). The Plan denied your request. The Plan 
says CPT codes 99291 and 49020 have been overturned. The Plan also says that CPT code 44005 is considered 
inclusive to CPT code 49020. 
  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 44005 
is a column II code to column I code 49020 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the freeing of bowel adhesion (44005) provided on March 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee 
appears to be more stable and improving and should only require short-term additional acute care services that 
can be safely administered at the current facility until more stable and appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to 
LTACH is not medically necessary at this time as it would not be clinically advantageous. Completion of 
treatment at the current acute care hospital is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is not an accepted standard of medical practice for the diagnosis or treatment of back pain.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusion analysis-mounted case (D9950), consultation-diagnostic service (D9310), repair of the resin of an upper partial denture base (D5612), diagnostic casts (D0470), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), intraoral-complete series of radiographic images (D0210), and the comprehensive oral evaluation (D0150) provided from October 20, 2021, through November 2, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services provided are not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the occlusion analysis-mounted case (D9950), consultation-diagnostic service (D9310), repair of the resin of an upper partial denture base (D5612), diagnostic casts (D0470), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), intraoral-complete series of radiographic images (D0210), and the comprehensive oral evaluation (D0150) provided from October 20, 2021, through November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) provided on November 
27, 2021, billed with code 93042. 
 
You asked the Plan to pay for the ECG interpretation. You say that this should be paid. The Plan denied your 
request. The Plan says a valid modifier was not used with the Column 2 code of this edit pair.  
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 93042 
is a column II code to column I code 93308. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) provided on November 27, 
2021, billed with code 93042.