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

 
We decided that the Plan does not have to pre-approve a powered arm orthosis (L8702). 
 
You asked the Plan to pre-approve the powered arm orthosis. You say that this device is medically necessary. 
The Plan denied your request. The Plan says the requested orthosis is experimental and non-covered. 
 
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 powered arm orthosis. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis will improve 
the long-term outcome for this patient, improve hemiparetic arm function, or be safe for long term use. 
 
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 powered arm orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a powered arm orthosis (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in interspinous spacer placement (22869, 22870). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is considered 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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve in interspinous spacer placement (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested items are a medical necessity for 
you. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 25, 
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 25, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging (SPECT) 
test provided on February 18, 2022. 
 
You asked the Plan to waive the copayment for the SPECT test. You say that the copayment amount is 
outrageous. 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 a $175 
copayment for each advanced radiology service, such as SPECT tests.  
 
You have been asked to pay a $175 copayment for the SPECT test. The SPECT test falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 a myocardial perfusion imaging (SPECT) test provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 15, 2021 by an out-of-
network (OON) chiropractor. 
 
You asked the Plan to pay for the office visit. You say that these services have been covered in the past. 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 the office visit provided on November 15, 2021 by 
an out-of-network (OON) chiropractor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service February 
8, 2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 
70450-26 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 70450-26 billed for date of service 
February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture, Initial 15-minute (97810). 
 
You asked the Plan to pre-approve the acupuncture services. You say that you are requesting additional 
acupuncture visits because you have a history of tongue cancer and acupuncture is the only thing that is helping 
you to swallow. The Plan denied your request. The Plan says this service exceeds the benefit frequency 
limitation. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture for diagnosis other than low back pain is 
limited to 10 visits per calendar year. The records show that the 10 visits had been processed and paid by the 
Plan. Therefore, we decided that the Plan does not have to pre-approve acupuncture, Initial 15-minute (97810).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the repeat ESI. You say that this should be approved as the enrollee has had 
good pain relief from this treatment. The Plan denied your request. The Plan says the enrollee did not have 
sufficient pain relief for a sufficient length of time to support a repeat ESI at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESIs may be covered when the enrollee 
has had at least 50% improvement in symptoms for at least three months.  
 
We looked at the file and Medicare rules. This repeat ESI was requested only after about one month. Prior ESI 
only provided 45% pain relief which is not sufficient based on the coverage rules. Based on this information, 
we decided that Medicare rules for coverage of the repeat ESI have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses provided on March 2, 2022. 
 
You asked the Plan to pay for progressive lenses. The Plan denied your request. The Plan says progressive 
lenses are not part of the allowed benefit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
 We looked at the file and the Plan's rules. The file shows that the Plan vision care benefit does not provide 
coverage for progressive lenses. Therefore, we decided that the Plan does not have to pay for progressive lenses 
provided on March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left shoulder surgery (23430, 29827, and 29823). 
 
You asked the Plan to pre-approve left shoulder surgery. You say that the requested left shoulder surgery is 
medically necessary. The Plan denied your request. The Plan says the requested left shoulder surgery 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 left shoulder surgery. Our reviewer says 
that the requested left shoulder surgery is not medically necessary. Our physician reviewer found the enrollee 
was being treated for tendinopathy of left rotator cuff; degenerative tear of glenoid labrum of left shoulder; 
superior labrum anterior-to-posterior (SLAP) tear of left shoulder; subacromial bursitis of left shoulder; and 
primary osteoarthritis of the left shoulder. She presented with increased left shoulder pain over the last 6 weeks. 
The exam of the left shoulder reveals physiologically normal motion. Strength is 4/5 in the left supraspinatus. 
Neers and Hawkins testing are positive on the left. There is tenderness of the greater tuberosity on the left. 
There is tenderness over the biceps tendon and intertubercular groove on the left. OBriens is positive on the left. Speeds testing is positive on the left. 
 
Provided documentation demonstrates subjective and objective deficits that are corroborated by imaging 
studies. However, trial and failure of recent, reasonable and comprehensive conservative treatment modalities 
has not been documented. Therefore, the requested left shoulder surgery is not medically 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 left shoulder surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left shoulder surgery (23430, 29827, and 29823).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laparoscopy procedure provided to the enrollee on April 
29, 2021. 
 
You asked the Plan to pay for the services. You say that this should bep aid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 38589 is "Unlisted laparoscopy procedure, lymphatic 
system." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the record indicates that the 
enrollee underwent laparoscopic esophagectomy. The record provided does not indicate that the enrollee 
underwent a distinct laparoscopic lymphatic procedure. 
 We looked at this coder'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 pay for a laparoscopy procedure provided to the enrollee on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for the periodontal maintenance (D4910) 
provided on November 1, 2021. 
 
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 50% 
coinsurance for Class 2 basic dental services which include a periodontal cleaning covered once every six 
months following active periodontal therapy, not to be combined with regular cleanings.     
You have been asked to pay $70.50 (Plan allowed amount of $141.00 x 50% coinsurance) for the periodontal 
service provided. 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 adjust the coinsurance for the periodontal maintenance 
(D4910) provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on June 23, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization or a referral. 
 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 Point of Service (POS) benefit allows you to access other 
services from non-network providers with a referral from your primary care physician.  
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
The Plan did not receive a referral from the enrollees primary care physician for this service. The Plan contract 
states that an enrollee must get a referral from their primary care physician (PCP) prior to getting care from 
out-of-network providers via the Point of Service (POS) benefit. If the enrollee does not get a referral, they will 
have to pay the full cost of any services received. We found no exception that would require the Plan to pay for 
this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0480) rendered by the 
out-of-network (OON) provider on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 8, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that these 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 lab services provided on November 8, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) 
provider on December 8, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on December 8, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on November 8, 2021. 
 
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 that the denied codes remain not supported. 
 
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 
the denied codes is: 
 
CPT 22853: 
 
Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation 
for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with 
interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) 
 
CPT 20930: 
 
Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in 
addition to code for primary procedure) 
 
CPT 22558: 
 
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for 
decompression); lumbar 
 
CPT 22840: 
 
Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, 
atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in 
addition to code for primary procedure) 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found all of the codes are able to be billed, and 
are all supported by the operative note. The codes are justified in the records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical services provided to the enrollee on November 8, 2021.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.