Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device 
(22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you strongly believe that coverage should 
be provided under the enrollee's Medicare Advantage Plan, which is based on the guidelines that they must 
comply with Original Medicare regulations and follow Medicare coverage in the respective region. The Plan 
denied your request. The Plan says there is lack of evidence to support interspinous spacer devices as safe and 
effective as the gold standard of surgical decompression. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion interspinous spacer device (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the denial of IRF services for this patient is 
unfounded and contradictory to the best outcome and appropriate care for this patient. You also say that this 
puts this patient at danger and high risk of further medical complications and deterioration. The Plan denied 
your request. The Plan says an intensive rehabilitation program is not medically necessary. 
 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 pre-approve SNF services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found there is no supporting documentation to why the 
patient would require an inpatient stay with close medical monitoring. Our physician reviewer also found that 
the patient has mobility impairments documented, but there is no mention on the patient's ability to tolerate an 
intensive rehabilitation program, and cellulitis is not an IRF compliant diagnosis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitoring (CGM) supplies. 
 
You asked the Plan to pre-approve the CGM supplies. You say that you believe the enrollee has medical 
necessity for continuous glucose monitoring. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for the requested CGM supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs 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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the continuous glucose monitoring (CGM) supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by his plastic 
and reconstructive surgeon and family medicine physician for myoelectric orthotic restoration. The Plan denied 
your request. The Plan says this item is considered experimental and investigational. There is insufficient 
evidence of its effectiveness in those with the enrollees health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro 2 Motion G orthotic device (L8702).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on December 29, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you passed out. You say that an ambulance 
was called. You also say that you were never transported because you became conscious. The Plan denied your 
request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 29, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopic knee surgery. 
 
You asked the Plan to pre-approve arthroscopic knee surgery. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 arthroscopic knee surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested 
arthroscopic knee surgery is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthroscopic knee surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthroscopic knee surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve The PureWick Urine Collection System (K1006). 
 
You asked the Plan to pre-approve The PureWick Urine Collection System (K1006). You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve The PureWick Urine Collection System 
(K1006). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has unspecified urinary incontinence. The 
documentation does not support that the requested Purewick system is not appropriate for home use. There are 
no peer-reviewed articles published in the medical literature specific to the PureWick system, or external 
urinary collection system using a continuous low-pressure pump. Thus, there is no evidence to show the 
PureWick system to be an effective alternative in managing urinary incontinence. 
 
 
 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 PureWick Urine Collection System (K1006) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve The PureWick Urine Collection System (K1006).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305, 88312, 88313) provided September 23, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 88305, 88312, & 88313 is not supported in the medical record. Specifically, a valid 
Clinical Laboratory Improvements Amendments (CLIA) number was not included on the claim. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (88305, 88312, 88313) provided September 23, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery 
(22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that per the enrollee's treating 
physician, the enrollee meets the medical necessity outlined in the criteria. The Plan denied your request. The 
Plan says this device is unproven and is not covered by Medicare as long term safety and efficacy has not been 
established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. There is not enough studies to show that Vertiflex Superion is safe 
and effective to treat back pain. Based on this information, we decided that Medicare rules for coverage of the 
Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the Vertiflex Superion device placement surgery (22869, 22870).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
March 26, 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 the claim is a duplicate. 
 
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 76641 is "Ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete." 
 We find that CPT code 76641 is not supported in the medical record. Specifically, the records for the two 
exams appear to be duplicates of each other. The records do not show any support for payment for multiple 
exams. 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 additional imaging services provided to the 
enrollee on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthesis services. 
 
You asked the Plan to pre-approve the prosthesis services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and there are providers who are in-network that can provide the same services. 
 
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 
prosthesis services
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultrasound bone growth stimulator (E0747, E0760). 
 You asked the Plan to pre-approve the bone growth stimulator. You say that you would like to appeal the 
outcome because you did not break any bone. The Plan denied your request. The Plan says the records do not 
show that the enrollee meets the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that this is not for a long bone fracture. The 
records indicate that you had surgery on 12/062021 for a broken hip. Based on this information, we decided 
that Medicare rules for coverage of the bone growth stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the ultrasound bone growth stimulator (E0747, E0760).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on December 28, 2021, to February 
22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. The Plan denied your request. The Plan says the services have 
been 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 visits provided on December 28, 2021, 
to February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2025, V2781, V2755, V2750) provided on 
February 8, 2022. 
 
You asked the Plan to pay for eyeglasses. You say that you were told your benefit would pay up to a $200 
allowance for these services. The Plan denied your request. The Plan says the cost of your eyewear was greater 
than the Plan's annual allowance, and you are responsible for the excess charges. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $200 allowance once every year. 
 
We looked at the file and the Plan's rules. The record shows that the provider billed the Plan $810 for the 
eyeglasses in question. You are being asked to pay $488 for these items. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not 
have to pay for the eyeglasses (V2025, V2781, V2755, V2750) provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polycarbonate lenses. 
 
You asked the Plan to pre-approve polycarbonate lenses. You say that you need the polarization to protect your 
eyes from macular degeneration. The Plan denied your request. The Plan says the requested service is not 
covered by Medicare or the Plan under any normal circumstances. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says that for premium frames, progressive lenses and additional lens treatment 
upgrades, you receive vision vendor's discounted rate. 
 
We looked at the file and the Plan's rules. The requested lens is not a covered benefit of Medicare or the Plan. 
Based on this information, we decided that the Plan's rules for coverage of polycarbonate lenses have not been 
met. Therefore, we decided that the Plan does not have to pre-approve polycarbonate lenses.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 home health physical therapy visits. 
 
You asked the Plan to pre-approve 13 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 13 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found at the time of 
the initial evaluation, the enrollee was walking 65 using a walker. At the time of the initial authorization 
request, the enrollee was walking 125 using a cane. As such, at the time of the health plans denial, the 
documentation did not support that the requested quantity of home health physical therapy services was 
medically necessary or reasonable. The enrollee was already functioning at a level commiserate with a lower 
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 13 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 13 home health physical therapy visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on February 24, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you submitted medical records so the 
claim can be processed. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an 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 psychotherapy services provided on February 
24, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150) provided on October 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87150) provided on October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on September 24, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the services should be covered as 
you disagree with the denial, you were unable to obtain authorization due to COVID-19. The Plan denied your 
request. The Plan says the services denied correctly as they were non-emergent and prior authorization was not 
obtained. 
 
 
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 outpatient hospital services provided on 
September 24, 2021, by an out-of-network (OON) provider.