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

 
We decided that the Plan does not have to pay for lab services provided on November 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 provided on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 provided on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of Neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve the auricular peripheral nerve stimulator device. You say that the enrollee 
has tried and failed conservative care and medication therapies. Based on the enrollee's history and diagnoses, 
the provider is recommending the neurostimulator to decrease pain. The Plan denied your request. The Plan 
says auricular neurostimulation is not covered by Medicare. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the auricular peripheral nerve stimulator device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the percutaneous implantation of Neurostimulator electrode array; peripheral 
nerve (excludes sacral nerve) (64555).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to review the amount applied to your deductible for services provided 
on February 10, 2022. 
 
You asked the Plan to review the amount applied to your deductible for services provided on February 10, 
2022. You say when the approved amount of $295.14 for services provided on February 10, 2022 was applied, 
your $500 deductible was exceeded. The Plan denied your request. The Plan says you are responsible for an 
annual $500 deductible. 
 
At the time this claim was processed, records show you had met $119.97 of your deductible. $500 - $119.97 = 
$380.03, therefore the $295.14 was correctly applied to your deductible. 
 
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 practitioner services. The item or 
service you asked the Plan to review the amount applied to your deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $500 deductible which applies to Physician/Practitioner Services, 
Including Doctors Office Visits. This cost sharing is a contractual obligation that had not been met at the time 
outpatient services was received on February 10, 2022. Therefore, we decided that the Plan does not have to 
review the amount applied to your deductible for services provided on February 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve the requested services. You say that it is hard for the enrollee to walk or go 
upstairs. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 requested services. Our physician 
reviewer found that the record indicates the enrollee has osteoarthritis of the knees. She has failed oral 
analgesics, but the record does not indicate that nonpharmacological therapy has failed. The record indicates 
previous benefit from physical therapy. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Euflexxa injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $750 copayment for an inpatient hospital stay from August 
1, 2021, to August 4, 2021. 
 
You asked the Plan to waive the $750 copayment for an inpatient hospital stay from August 1, 2021, to August 
4, 2021. You say that you are not responsible for the copayment because you read that the Plan was waiving 
cost share responsibilities associated with the treatment of COVID. The Plan denied your request. The Plan 
says for days 1 - 7 of an inpatient stay, enrollees must pay a $250 per day copayment. 
 
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 $250 
copayment per day for Inpatient Hospital Care.  
 
Please note the Plan discontinued their voluntarily implemented waivers effective May 31, 2021. Your 
inpatient hospital stay was after this date. 
 
 You have been asked to pay a $750 copayment for an inpatient hospital stay from August 1, 2021, to August 4, 
2021 ($250 x 3= $750). An inpatient hospital 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 $750 copayment for an inpatient hospital stay from August 1, 2021, to 
August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device (22869, 
22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you hope for a favorable outcome to 
approve this preauthorization request and provide the necessary coverage that the enrollee should be entitled to. 
The Plan denied your request. The Plan says this item is considered experimental and investigational. Medical 
studies have not proven that this device is helpful for the 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. 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 device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 25, 2021. 
 
You asked the Plan to pay for the office visit. You say that the doctor's office told you the coverage was $20 
per treatment. You say that the treatments help, and you want to continue them. The Plan denied your request. 
The Plan says procedure code 98941 has been overturned and you are only responsible for the $20 copayment. 
The Plan also says that procedure code 99202 remains denied as a non-covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
An office visit is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to 
pay for the office visit provided on October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve Vertiflex Superion Interspinous device. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services 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 Vertiflex Superion Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have lumbar spinal stenosis with neurogenic claduication. The 
vertiflex device is experimental. More research is needed. Therefore, you do not meet criteria for the requested 
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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient surgery to be provided at the in-network 
benefit level by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient surgery. You say that you would like reconsideration of the 
denied authorization due to the complexity of the surgery needed. The Plan denied your request. The Plan says 
the denial of authorization for in-network benefits is correct, because this provider is out-of-network with the 
Plan, and you may choose to visit this provider using your Point-of-Service (POS) benefits. Also, there are in-
network providers that are available that provide the same service. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers using the Plans Point-of-
Service (POS) benefits. 
 
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 at the in-network benefit levels. You may choose to receive 
services from this provider using the Plans Point-of-Service (POS) benefits. Therefore, we decided that the 
Plan does not have to pre-approve the outpatient surgery to be provided at the in-network benefit level by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve intravenous immunoglobulin (IVIG) services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is stable on IVIG 
treatment. The Plan denied your request. The Plan says that the enrollee's condition has been stable. 
 
The Plan must follow Medicare rules. Medicare rules say that intravenous immunoglobulin is only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that in this case, the enrollee is noted to have a history of MG (diagnosed in 2012). Her 
condition is said not to have responded adequately in the past to Mestinon and Prednisone. Imuran may be 
contraindicated given a history of skin cancer. In such a setting it would otherwise be consistent with the 
requirements of the coverage criteria and practice guidelines (Sanders et al) to treat the enrollee with IVIG. 
Doing so would be expected to prevent progressive and/or potentially life-threatening muscular weakness. 
Therefore, this would meet Medicare criteria for coverage. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve intravenous immunoglobulin (IVIG) services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested Vertiflex procedure is considered 
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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex procedure is experimental for back pain and will not be covered by 
Medicare or the Plan. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist office visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visits. You say that documentation was provided so the 
enrollee can see an OON specialist. The Plan denied your request. The Plan says the requesting provider of 
services is an OON provider and there are multiple in-network providers within the enrollee's service area that 
provide the same quality of service and are accepting new members. 
 
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 
the specialist office visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement oxygen equipment (E0431, E1390). 
 
You asked the Plan to pre-approve the replacement oxygen equipment. You say that replacement oxygen 
equipment is medically necessary. The Plan denied your request. The Plan says the enrollee already has oxygen 
equipment. Coverage rules for new equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have oxygen equipment. The requested replacement equipment serves the same 
purpose.  
 
 
 
  
 
The records do not show that the equipment you have has been irreparably damaged, lost, or stolen. Therefore, 
we decided that the Plan does not have to pre-approve replacement oxygen equipment (E0431, E1390).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this request would exceed the three-scan limit. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan. Our reviewer says that the 
requested PET scan is medically necessary. Our physician reviewer found the requested imaging is indicated to 
evaluate for progression of metastatic lesions and eligibility for directed therapy, which is supported by current 
guidelines. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a Positron Emission Tomography (PET) scan.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 provided on September 16, 2021.