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

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for 
treatment of the enrollee's health problem. 
 
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 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. Therefore, the requested Vertiflex superion interspinous 
device at the L3-4 level 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you were in a car 
accident, and you are now unable to drive yourself to any of your doctors appointment and need additional 
transportation to get to your future doctors appointments. The Plan denied your request. The Plan says you 
have exhausted your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. Your request exceeds your 
benefit. The 25th trip and beyond is not a covered benefit. Your 2022 EOC says up to 24 one-way trips are 
covered each year (limited to ground transportation only). Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation trips.
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 LTACH is the most appropriate level of 
care for the enrollee. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
LTACH services do not meet the requirements for approval. 
 
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 that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until April 28, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on December 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99214) provided on April 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is included in the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 We looked at the file and Medicare rules. Payment for the requested services is included in the global surgery 
payment for the procedure (35556) provided on February 15, 2022. Code 35556 has a 90-day global period. 
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 the services (99214) provided on April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (99222-25) provided on November 7, 2021. 
 
You asked the Plan to pay for initial hospital care. You say that these services were billed correctly and are 
supported in the medical record. The Plan denied your request. The Plan says that Medicare designates code 
99222 with a status indicator of "A" which means this service is bundled. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has only indicated that this is a bundled service with a 
status indicator of A on the Physician Fee Schedule. Services with a status indicator of A are active codes 
which are eligible for separate payment. The Plan has not provided any other clear argument in their denial 
explaining any other reason this service might be bundled in this specific case, and no supporting citation was 
included with this argument. Therefore, we decided that the Plan has to pay for initial hospital care (99222-25) 
provided on November 7, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve basivertebral nerve ablation (64628, 64629). 
 
You asked the Plan to pre-approve the basivertebral nerve ablation. 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 basivertebral nerve ablation. 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 basivertebral nerve ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve basivertebral nerve ablation (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 19, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the cortisone injection provided on May 3, 2022. 
 
You asked the Plan to pay for the injection. You say that this claim is not related to Worker's Compensation. 
You say that The Plan denied your request. The Plan says that payment cannot be made until the decision 
information has been provided from the primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, there is no evidence 
that the Plan has made efforts to coordinate their benefits with the primary insurer. As the secondary insurer, 
the Plan will be held responsible for the injection until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan has to pay for the cortisone injection provided on May 3, 2022.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eye movement desensitization and reprocessing 
(EMDR) therapy to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON EMDR therapy services. You say that you are improving with 
OON therapy, and you feel that the plan does not have the specialists that you need to see with their psychiatric 
department who are LBTQIA inclusive. The Plan denied your request. The Plan says they have network 
providers who are able to treat you. 
 
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. Specifically, the Plan has a therapist who 
they have referred you to who is a LBGTQ+ provider and who provides mental health treatment specifically 
through the framework of an LGBTQ+ inclusive lens. We found no exception that would require the Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-approve eye movement 
desensitization and reprocessing (EMDR) therapy to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (CPT) code J0585). 
 You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed or has documented adverse 
effects/contraindications to the preferred treatments. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Botox (CPT code J0585) have been 
met. Records were not provided to verify if the enrollee meets the step therapy guidelines. Therefore, we 
decided that the Plan does not have to pre-approve Botox (CPT) code J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628) and thermal destruction of 
intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or 
sacral (64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedures are not medically necessary. There is not 
enough proof to show it works and is safe. Medicare rules say that experimental and investigational devices are 
not 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure targets the basi-vertebral nerve for the relief of chronic 
vertebrogenic low back pain. Medicare guidelines consider this type of system unproven, not medically 
necessary, and this type of treatment is considered experimental/investigational. Large well-designed studies in 
the peer review scientific literature comparing stand-alone use of the Intracept device to established surgical 
decompression are needed. Published studies do not demonstrate any long-term health outcome advantage with 
the use of Intracept as an alternative to standard surgical treatment. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628) and thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (64629).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are having surgery 
and will require you to see providers before and after the surgery. The Plan denied your request. The Plan says 
you have exhausted your benefit 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. We looked at your request, the records in the case file, and the rules. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Your request exceeds 
your benefit. The 21st trip and beyond is not a covered benefit. Your 2022 EOC says up to twenty (20) one-way trips every year to plan-approved locations. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for hearing aids received on February 10, 
2022. 
 
You asked the Plan to pay an additional amount for hearing aids. You say that you want the Plan to pay an 
additional amount for the items. The Plan denied your request. The Plan says the portion of the hearing aid 
purchase paid by applying the credit card reward points of $800.99 is not reimbursable. The Plan reimburses  
for covered services and/or items when paid using cash, check, or credit card, but not credit card points. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay an 
additional amount for hearing aids received on February 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271) and Zoledronic Acid 
(J3489). 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the accepted use of this drug for the enrollee's condition requires 
pemrbolizumab will be used as a single agent AND one of the following: documented microsatellite instability-
high (MSI-High) solid tumor or documented mismatch repair deficient (d-MMR) solid tumor or documented 
tumor mutational burden-high (TMB-H) (greater than or equal to 10 mutations/megabase (mut/Mb)). 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the review has determined that the requested use of Keytruda (J9271) and Zoledronic Acid (J3489) is not 
FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug compendia or by 
clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (CPT code J9271) and Zoledronic Acid (J3489).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint RFA procedure. 
 
You asked the Plan to pre-approve the services. You say that the lumbar facet joint radiofrequency ablation 
procedure is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not 
been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found the review has determined that the requested RFA is not medically reasonable or necessary 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar facet joint RFA procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided April 23, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that your records indicate that the claim was filed 
within timely filing guidelines. The Plan denied your request. The Plan says the claim was filed past the timely 
filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital care was not filed until May 5, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care (99232) provided April 23, 2021.