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

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the enrollee has 
suffered from this condition for over 10 years and has failed more than 6 months of conservative approaches to 
treatment. You say that you recommend this minimally invasive procedure when conservative treatment has 
failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The 
Plan says there is a lack of evidence to support that interspinous spacer devices are safe and effective. 
 
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 insertion of stabilization device 
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that interspinous process stabilization devices are 
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 insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
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 enrollee would benefit from IRF care. The Plan 
denied your request. The Plan says the requested IRF admission does not meet criteria for coverage. 
 
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 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: 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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have 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 that you were admitted for peritonitis, surgical management of bowel perforation and 
abdominal wound infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553), provided on August 16, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the member received an unsolicited call pertaining to the CGM. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) (K0554) and supplies (K0553), provided on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (L1686), and addition (L2624), provided on 
October 14, 2021. 
 
You asked the Plan to pay for the hip orthosis and addition. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the medical records do not support the order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case.There is no evidence of medical necessity or mention of the ordered items in the medical records submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the hip orthosis (L1686), and 
addition (L2624), provided on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650), and shoulder immobilizer (L3670), 
provided on October 29, 2021. 
 
You asked the Plan to pay for the back brace and shoulder immobilizer. You say that the items are medically 
necessary. The Plan denied your request. The Plan says there is insufficient medical records to support the 
order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records submitted do not indicate medical necessity or mention the need of the items 
ordered. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the back brace (L0650), and shoulder 
immobilizer (L3670), provided on October 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient rehabilitation provided from 
January 29, 2021, to February 10, 2021, and February 17, 2021, to February 27,2021. You also asked the Plan 
to waive the copayment for an intensive care unit (ICU) stay provided from February 10, 2021, to February 17, 
2021. 
 
You asked the Plan to waive the copayments for inpatient rehabilitation and an ICU stay. You say that you 
already had met your maximum out-of-pocket (MOOP). The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. The Plan also says that they confirmed that after receiving 
services on February 27, 2021, you had only met $5,431.46 of your $5,900 out-of-pocket maximum. 
 
 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 per day for days 1-5 for inpatient hospital care. There is no charge for additional days after day 5. 
The Plan contract also says a transfer to a separate facility type is considered a new admission. 
 
The record shows you had not met your MOOP at the time the inpatient services took place from January 29, 
2021, to February 27, 2021. You have been asked to pay a total of $1,250, which is a $250 copayment for the 
first five days of inpatient rehabilitation from January 29, 2021, to February 10, 2021 ($250 copayment x 5 
days = $1,250). You have also been asked to pay the total of $1,250, which is a $250 copayment for the first 
five days of an ICU stay from February 10, 2021, to February 17, 2021 ($250 copayment x 5 days = $1,250. 
You have also been asked to pay a total of $1,250, which is a $250 copayment for the first five days of 
inpatient rehabilitation from February 17, 2021, to February 27,2021 ($250 copayment x 5 days = $1,250. 
There is no charge for additional days after day 5. Even though you were not discharged from the hospital, a 
transfer to a separate facility type is considered a new admission and new cost sharing applies. Inpatient 
rehabilitation and an ICU stay falls within the Inpatient Hospital Care 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 copayments for inpatient rehabilitation provided from January 29, 2021, to February 
10, 2021, and February 17, 2021, to February 27,2021. You also asked the Plan to waive the copayment for an 
intensive care unit (ICU) stay provided from February 10, 2021, to February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the lateral sacral 
branches (64625). 
 
You asked the Plan to pre-approve a radiofrequency ablation of the lateral sacral branches. You say that the 
requested services are a medical necessity for you. The Plan denied your request. The Plan says rules for 
coverage have not been met because the requested procedure is experimental/investigational. 
 
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 a radiofrequency ablation of the lateral 
sacral branches. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the requested procedure is considered 
experimental/investigational therapy because of the wide variation in efficacy in the peer-reviewed literature. 
 
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 radiofrequency ablation of the lateral sacral branches have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the 
lateral sacral branches (64625).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. You say that the enrollee was given the requested medication while 
in the hospital and it helped her. You say that when the enrollee was discharged and not taking the requested 
medication, she became critical again. The Plan denied your request. The Plan says Granix is subject to their 
step therapy criteria. The Plan says that the enrollee is eligible for coverage of their preferred G-CSF, Zarxio. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Granix. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Zarxio 
and Nivestym before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the Plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.
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 care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have 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 that the patient is a 77-year-old male who was admitted to the acute care hospital 
with acute respiratory failure. He required mechanical ventilation support. Recent notes describe the patient as 
now having been extubated successfully and having recently with an implantable cardioverter defibrillator 
placement without complication, however, the patient is still requiring high flow  oxygen support (15L) and is 
still being treated for pneumonia with intravenous antibiotics for a few more weeks. The patient appears to be 
more stable and improving and should only require short-term additional acute care services that can be safely 
provided by the current facility until appropriate for a lower level of care. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
patient requires that are not already available and covered at the current facility.Transfer to LTACH is not 
medically necessary at this time as it would not be clinically advantageous. Transfer to a lower level of care 
may be considered when treatment has completed. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on October 28, 
2021, to November 2, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be paid by the Plan. The Plan 
denied your request. The Plan says this claim must be submitted to Original Medicare first. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided to the enrollee on October 28, 
2021, to November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
15, 2021. 
 
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 December 15, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service 
November 23, 2021. 
 You asked the Plan to pay for procedure code 76705-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705-26 billed for date of service November 23, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for telehealth specialist visits provided on 
November 12, 2021, and November 22, 2021. 
 
You asked the Plan to reduce the copayments for telehealth specialist visits. You say that you had two phone 
calls with your provider on November 12, 2021, and November 22, 2021. You also say that all e-visits should 
be $5 as it says in the EOC, not $35. 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 $35 
copayment for each in-network telehealth specialist visit. The Plan contract also says that a telehealth visit can 
be done over the phone or through video conferencing. The Plan contract also says that enrollees must pay a $5 
for each in-network eVisit consultation. The contract says that an eVisit is for common medical and skin 
conditions. 
 
The record shows you had phone calls with a specialist provider on November 12, 2021, and November 22, 
2021. These phone calls are telehealth visits, not eVisits. You have been asked to pay a $35 copayment for 
each telehealth specialist visit. You have been asked to pay a total of $70 ($35 copayment + $35 copayment = 
$70). Telehealth specialist visits fall within the Physician/Practitioner Services, Including Doctor's Office 
Visits 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 telehealth specialist visits 
provided on November 12, 2021, and November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that medical records show different specimen numbers. 
The Plan denied your request. The Plan says the claim is an exact duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. The file shows that procedure codes 87070, 87075, 87102, 87106, and 
87205 were billed twice for the same date of service and same provider. The records and claims do now show 
that subsequent lab tests were performed on the same day in order to obtain new data. 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 the lab services provided on April 21, 2021.