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

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99291 is bundled into payment for code 36558. 
 
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 99291 
is a column II code to column I code 36558. 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 99291 billed for date of service July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician services provided on June 27, 
2022. 
 
You asked the Plan to waive the copayment for physician services. You say that the enrollee should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $10 
copayment for physician services. 
 
You have been asked to pay a $10 copayment for physician services. This item/service falls within the 
physician services 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 physician services 
provided on June 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fusion of the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve fusion of the sacroiliac (SI) joint. You say that the requested fusion of the 
sacroiliac (SI) joint is medically necessary. The Plan denied your request. The Plan says the requested fusion of 
the sacroiliac (SI) joint 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 fusion of the sacroiliac (SI) joint. Our 
reviewer says that the requested fusion of the sacroiliac (SI) joint is not medically necessary. Our physician 
reviewer found the imaging studies do not show any evidence of SI joint pathology. SI joint fusion for 
degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fusion of the sacroiliac (SI) joint have not been met. Therefore, we decided that 
the Plan does not have to pre-approve fusion of the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and a segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and a segmental pneumatic appliance. You say that 
the requested items are not available from in-network providers. The Plan denied your request. The Plan says 
the enrollee must receive care from 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 compressor and a segmental pneumatic appliance to be provided by an out-of-network (OON) 
provider.
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 IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status and sepsis. Medical problems are stable. There are no complex nursing 
or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit on July 21, 2022. 
 
You asked the Plan to waive the deductible for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $233 deductible which applies to Physician/practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $233 deductible which applies to Physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
office visit was received on July 21, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for office visit on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 04, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 provided on May 04, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion (27279). 
 
You asked the Plan to pre-approve sacroiliac joint fusion (27279). You say that the requested sacroiliac joint 
fusion (27279) is medically necessary. The Plan denied your request. The Plan says the requested sacroiliac 
joint fusion (27279) 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 sacroiliac joint fusion (27279). Our 
reviewer says that the requested sacroiliac joint fusion (27279) is not medically necessary. Our physician 
reviewer found there is no sacroiliac joint instability, fracture, or lesion. The enrollee has degenerative low 
back pain and previous surgery for lumbar fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion (27279) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve sacroiliac joint fusion (27279).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid service provided on June 16, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid service. You say that you were told that the hearing air was 
covered and purchased the hearing aids from the same provider as the previous purchase seven years ago. The 
Plan denied your request. The Plan says the provider was out-of-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 
hearing aid service. We found no exception that would require the Plan to pay for hearing aid service. 
Therefore, we decided that the Plan does not have to pay for the hearing aid service provided on June 16, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saxenda injector pen. 
 
You asked the Plan to pre-approve Saxenda. You say that this is important for the enrollee. The Plan denied 
your request. The Plan says this drug is not covered by Medicare Part B and the Plan does not administer the 
enrollee's Medicare Part D prescription drug benefits. 
 
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 Saxenda injector pen.  
 
Benefits for Saxenda 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone growth stimulator (E0747). 
 
You asked the Plan to pre-approve an electrical bone growth stimulator (E0747). You say that the requested 
electrical bone growth stimulator (E0747) is medically necessary. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for an electrical bone growth stimulator (E0747). 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 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 electrical bone growth stimulator 
(E0747). Our reviewer says that the enrollee does not meet criteria for an electrical bone growth stimulator 
(E0747). Our physician reviewer found the enrollee was being treated for left femur fracture. He presented with 
left hip pain that is rated at 7, occurs occasionally, and has improved. The exam of the left hip reveals an 
antalgic gait. There is maximum tenderness over the greater trochanter. Obers is positive. There is limited 
range of motion with pain. Strength is 5/5. 
 
However, the documentation does not include two sets of radiographs separated by a minimum of 90-days, 
which include multiple views of the fracture site accompanied with a written interpretation by a physician 
stating that there has been no clinically significant evidence of fracture healing between the two sets of 
radiographs. Therefore, the enrollee does not meet Medicare criteria for the requested electrical bone growth 
stimulator. 
 
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 electrical bone growth stimulator (E0747) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electrical bone growth stimulator (E0747).
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 IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of a leg infection and hypotension and is living in an assisted living facility with 
weakness despite home health physical therapy. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in 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. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from June 25, 2022, to July 24, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee did not require daily skilled nursing services such as the administration of 
IV antibiotics, the management and education of a new percutaneous endoscopic gastrostomy (PEG) tube or 
ostomy, or the complex management of wounds. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that the patient 
required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse were not required to safely and effectively provide medically necessary and reasonable treatment from 
June 25, 2022 through July 24, 2022. The records did not document the need for intravenous medications, new 
tube feeding or ostomy care or daily complex wound care or respiratory care. Although the records document 
the patient was quite limited functionally, provided records do not document a significant decline in the 
patients functional status compared to her recent baseline to necessitate further daily inpatient skilled therapy 
services. Part time therapy in long term care appeared appropriate as of June 25, 2022. Services in the nursing 
facility appear custodial in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from June 25, 2022, to July 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 13, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you feel you should not be billed 
for a follow-up visit. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $40 
copayment for physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $40 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist) 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 office visit provided on May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeve 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the beneficiary does not have lymphedema extending 
onto the chest, trunk and/or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and sleeve (E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of post-
menopausal osteoporosis and history of intolerance to alendronate. She has not tried and failed the Plan's 
required drug, zoledronic acid. The records do not show that the required drug would be contraindicated or less 
effective; therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.