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

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on August 9, 
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 there is a more appropriate code to use. 
 
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 00790: 
 
Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified 
 
CPT 64488: 
 
Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed) 
 
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 in terms of CPT 00790, the 
operative report describes a right coloectomy.  Anesthesia for intraperitoneal procedures in upper abdomen is 
an incorrect code to report for procedure performed. In terms of CPT 64488, the operative report documents 
"Entereg as  tap block". Anesthesia report does not document a TAP was performed. In this case, the 
documentation does not support that this service was performed, as well as, for post operative pain, and 
therefore cannot be verified. 
 
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 anesthesia services provided to the enrollee on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara lung expansion system (E1399). 
 
You asked the Plan to pre-approve the Volara lung expansion system. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this device 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 the Volara lung expansion system. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this patient has cystic fibrosis with associated lung disease and 
bronchiectasis. Airway clearance is part of her treatment regimen. The Volara System combines positive 
airway pressure, airway oscillation, and medication nebulization. The airway oscillation component has not 
been shown to be superior to or as good as chest wall oscillation for airway clearance. The patient already has a 
nebulizer, so this represents duplication.  Lung expansion with positive airway pressure has not been shown to 
be beneficial in this setting. 
 
 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 Volara lung expansion system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Volara lung expansion system (E1399).
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may benefit from additional multiple therapies, including physical and occupational therapy, the documentation does not 
reveal that you require this therapy or can tolerate this on an intensive IRF level. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lower extremity for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is imperative to correctly diagnose and treat the 
enrollee's condition. The Plan denied your request. The Plan says that conservative management has not been 
documented. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found residual neuroma is a real 
possibility in this patient, and a 6 week trial of physical therapy is not necessary to determine if there is medical 
necessity for MRI. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the lower extremity for the enrollee.  
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One Touch Test Strips (A4253) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve One Touch Test Strip. You say that you have been using Verio glucometer 
for 5 years and feels very comfortable using it. You had tried the Freestyle Libre and did not feel confident in 
the quality and found it was more difficult to use. The Plan denied your request. The Plan says this item is not 
covered under the Plan benefits. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that contract suppliers are not required to furnish a specific brand 
name item or mode of delivery to a beneficiary. 
 
One Touch Test Strips is a non-preferred product and not a covered benefit. Abbott Diabetes Care (ADC) test 
strips are the sole preferred products that are coverable. 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 One Touch 
Test Strips (A4253) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. The Plan denied your request. The Plan says 
radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational 
whether performed using traditional, cooled, or pulsed radiofrequency. 
 
The Plan follows Medicare rules.  
 
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 radiofrequency ablation. Our reviewer 
says that radiofrequency ablation is not medically reasonable or necessary. Our physician reviewer found 
procedure is considered an experimental/ investigational procedure because of the wide variation in efficacy as 
published in the peer reviewed literature. Therefore, the request is considered 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the enrollees 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 the non-surgical management of radial and ulnar fractures after a fall. The 
enrollees 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, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
Additionally, there is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from an intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you are not working and cannot afford 
to pay this copayment. 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 $250 
copayment for diagnostic radiology services, including CT scans.  
 
 
 You have been asked to pay a $250 copayment for a CT scan. A CT scan 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 computed tomography (CT) scan of the abdomen and pelvis provided on December 15, 2021.
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 services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 there is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 copayment for a podiatry office visit provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for a podiatry office visit. You say that you are a diabetic and were 
supposed to be covered without a copayment. You also say that you only went there to get your toenails 
clipped. 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 $25 
copayment for a podiatry office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$25 copayment for a podiatry office visit. A podiatry office visit falls within the Podiatry 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 a podiatry office visit provided on December 
15, 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 these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is little evidence in the medical literature to suggest that this 
is an appropriate procedure for the enrollee's 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The non-radiating 
midline back pain, the noted pain-aggravating and pain-relieving factors, with the diminished and painful 
spinal motion (in all directions) and intact neurologic exam were/are all non-specific to any pathologic entities. 
In this case, there are multiple plausible pathologic sources of significant pain generation. Overall, 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. Our 
physician reviewer found that the enrollee's 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 the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the insertion of a neurostimulator 
generator provided on October 6, 2021, and October 20, 2021. 
 
You asked the Plan to reduce the copayments for the insertion of a neurostimulator generator. You say that you 
received a bill in the mail for $125 that you do not owe. 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 $250 
copayment for each outpatient surgery provided at an outpatient hospital.  
 
The record shows these claims were approved, and you have a cost sharing amount for each procedure. You 
have been asked to pay a $250 copayment for each insertion of a neurostimulator generator on October 6, 2021, and October 20, 2021. The insertion of neurostimulator generator falls within the Outpatient Surgery and Other 
Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayments for the insertion of a neurostimulator generator provided on 
October 6, 2021, and October 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a breast ultrasound provided on December 
13, 2021. 
 
You asked the Plan to waive the deductible for an ultrasound. You say that this was a preventative service and 
should be covered at 100%. 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. Your 
contract with the Plan says that there is $500 deductible which applies to an in-network ultrasound.  
 
The record shows a screening mammogram, and a breast ultrasound are two different services. A breast 
ultrasound is not considered a preventative screening. The ultrasound you asked the Plan to waive the 
deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 
deductible which applies to an ultrasound.  This cost sharing is a contractual obligation that had not been met at the time an ultrasound was received on 
December 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a breast 
ultrasound provided on December 13, 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 services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's needs are met in the current acute care setting. The LTACH offers no 
services that are not currently available. 
 
 
 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trident Falcon power wheelchair. 
 
You asked the Plan to pre-approve a Trident Falcon power wheelchair. 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 follows Medicare rules. Medicare rules say that the rules say that plans may specify brands and 
manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to 
only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary 
items (including non-preferred brands). 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Trident Falcon power wheelchair. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found per clinical 
documentation you would meet criteria for a prescribed light weight power wheelchair however, nothing is 
mentioned about the specific brand requested in the documentation. Thus, the requested item does not meet 
criteria. The health plan is allowed to restrict medically necessary care to in-network. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Trident Falcon power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Trident Falcon power wheelchair.