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

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that you cannot walk without your back 
being in pain. You need to use a TENS unit to even get around. The Plan denied your request. The Plan says 
interspinous fixation devices are considered investigational. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, Vertiflex procedure 
(22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the high frequency chest wall oscillation system 
(E0483). 
 
You asked the Plan to pre-approve the high frequency chest wall oscillation system. You say that the enrollee 
has a hiatal hernia and is causing diaphragmatic weakness and difficulty clearing secretions and is a candidate 
for effective airway clearance therapy. The Plan denied your request. The Plan says the medical records 
received do not support that the enrollee meets the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve the high frequency chest wall oscillation system (E0483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 6, 2021, to 
March 12, 2021 at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the medical records do not support the billing of diagnosis code A41.9. Our physician 
reviewer found the enrollee presented to the facility with the chief complaint of shortness of breath, fever, and 
weakness. She was noted to have elevated brain natriuretic peptide (BNP) and was evaluated for cellulitis of 
the leg. Peripheral exams were all normal without provider support of hemodynamic instability present. There 
is no clinical or laboratory evidence of sepsis. The records do not support the billing of principal diagnosis code 
A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 6, 2021, to March 12, 2021 at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued oxygen equipment rental. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee has exhausted the rental period limit. 
 
The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 
monthly rental payments.  
 
We looked at the file and Medicare rules. The request is for oxygen equipment beyond the 36 monthly rental 
period. 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 continued oxygen equipment rental.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode chair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that the enrollee is confined to a bed or room as defined by Medicare rules. Therefore, 
we decided that the Plan does not have to pre-approve a commode chair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you still need rehab services. The Plan denied your 
request. The Plan says SNF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that as of the last covered day you did not require daily skilled nursing or 
rehabilitation services. Your function was at or near your new baseline level of function and you can be 
discharged to a lower level of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiogram (CTA) of the 
abdominal aorta and lower extremity runoff. 
 
You asked the Plan to pre-approve the requested CTA. You say that it is felt that the enrollee would benefit 
from this imaging. The Plan denied your request. The Plan says there is no clinical indication for this imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the requested CTA. Our reviewer says 
that the requested imaging is not shown to be medically necessary. Our physician reviewer found there was no 
evaluation of pulses on physical exam and no description of claudication (how many blocks, have frequent, 
how long it takes for the symptoms to resolve, etc.). Additionally, there is no indication of rest pain or tissue 
loss. The review has determined that the CT scan 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 requested CTA have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography angiogram (CTA) of the abdominal aorta and lower extremity 
runoff.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs provided to the enrollee on July 6, 2022. 
 
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this was provided within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, the global period for the 
surgery was for the same day. These drugs were provided for the surgery on the same day and should not be 
billed separately. Based on this information, we decided that Medicare rules for coverage of the drugs have not 
been met. Therefore, we decided that the Plan does not have to pay for drugs provided to the enrollee on July 6, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine 10mg tablets. 
 
You asked the Plan to pre-approve the prochlorperazine tablets. You say that this is needed to treat nausea 
related to chemotherapy. The Plan denied your request. The Plan says this is not being used during 
chemotherapy, which means it must be covered by Part D. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 
The oral anti-emetics requested here are not for a Medicare Part B-covered indication. Therefore, we decided 
that the Plan does not have to pre-approve prochlorperazine 10mg tablets.  
 Benefits for the prochlorperazine tablets may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating legrests for a high-strength wheelchair. 
 
You asked the Plan to pre-approve elevating legrests for a high-strength 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 elevating legrests are covered when specific criteria 
are 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 elevating legrests for a high-strength 
wheelchair. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
there is no presence of a contracture brace or cast or edema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of elevating legrests for a high-strength wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve elevating legrests for a high-strength wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on February 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a facility visit. You say that requesting reconsideration of the above referenced 
claim. 
the enrollee is in a facility and the facility should have obtained the prior authorization. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a facility visit provided on February 16, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electronic analysis of programmable implanted pump 
provided on March 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for electronic analysis. You say that you verified that you have not obtained 
authorization, so you have attached complete medical records for the rendered service. The Plan denied your 
request. The Plan says they were not approved in advanced. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for electronic analysis of programmable implanted 
pump provided on March 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 24, 2022. 
 
You asked the Plan to pay for physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in 
cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting the extension of rehabilitation 
due to medical concerns. The Plan denied your request. The Plan says that continued SNF care is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that you have improved with skilled therapy 
and have met your goals. Based on the clinical documentation there is no specific recommendation or 
reasoning for daily skilled therapy or skilled nursing thus continued daily skilled services in a SNF setting is 
not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 12, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $10 
copayment for Lab services. 
 
You have been asked to pay a $10 copayment for laboratory services. This item/service falls within the Lab 
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 laboratory services 
provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 24, 2022. 
 
You asked the Plan to pay for physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the Plan has to pay for care from out-of-network providers only in 
cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 12, 2022. 
 
You asked the Plan to pay for physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in 
cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 is experimental. 
 
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 an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensor. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee injects 
insulin once a day and does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre 2 Sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 2 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal crown for tooth #12 (D2751), an 
exam (D0140), and upper and lower jaw x-rays (D0330). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. Also, the 
service is part of another benefit and is not separately billable. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve white glass with metal crown for tooth #12 (D2751), an exam (D0140), and upper and 
lower jaw x-rays (D0330).