Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ROMtech portable connect adaptive rehabilitation 
device. 
 
You asked the Plan to pre-approve the device. You say that the prescribed equipment will aid in the 
symptomatic relief of pain, increase local blood flow, stimulate soft tissue healing, increase range of motion, 
aid in muscle reeducation and the relaxation of muscle spasms. You state the enrollee's use of this equipment in 
their home will thus minimize the necessity for narcotic pain medications. You state that a home unit as part of 
the enrollee's treatment protocol will facilitate their quicker return to functional restoration and participation in 
the activities of daily living. The Plan denied your request. The Plan says the requested service is not covered 
by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
A ROMtech Portable Connect device is a type of exercise equipment and exercise equipment is not covered by 
Medicare. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This 
item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve ROMtech portable connect adaptive 
rehabilitation device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammaplex (J1557) to be dispensed for home 
administration. 
 
You asked the Plan to pre-approve Gammaplex (J1557). You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Gammaplex is not covered under the enrollee's 
Medicare Part B benefit when being dispensed for home administration. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought home for administration. Since the medication does not represent an expense to the physician and will 
not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan 
does not have to pre-approve Gammaplex (J1557) to be dispensed for home administration.  
 
 
 
 
 
 
  
Benefits for Gammaplex (J1557) 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endovenous ablation therapy of incompetent vein, extremity, 
inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated (CPT code 
36475). 
 
You asked the Plan to pay for the service. You say that for the enrollees vein insufficiency, this procedure is 
medically necessary. You state the enrollee would have discomfort in the legs without this procedure. The Plan 
denied your request. The Plan says your request for treatment of varicose veins is not medically necessary 
because the documentation does not support symptoms or signs of venous insufficiency or failure of 
conservative management. 
 
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 service. Our physician reviewer found 
the LCD criteria are not met as this is not satisfactory documentation of the enrollee's symptoms and no VCSS 
provided. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance 
and monitoring, percutaneous, radiofrequency; first vein treated (CPT code 36475).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on September 
24, 2021. 
 You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 76705 
and 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 the abdominal ultrasound (76705) provided on September 24, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not 
tried and failed an oral bisphosphonate and zoledronic acid. 
 
 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 Prolia. Our physician reviewer found 
that the enrollee has osteoporosis. The Plan requires a trial of an oral bisphosphonate and Zoledronic acid 
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 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code G0482) provided on July 
22, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Healthcare Common 
Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not supported. The place of service on the 
CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an office 
setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 22, 2021, 
and received by the lab on July 26, 2021. It is noted multiple attempts were made to obtain additional 
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
service (CPT code G0482) provided on July 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need to leave the hospital, but it is not safe to 
return back home, and you need assistance at a Skilled Nursing Facility due to personal care needs. The Plan 
denied your request. The Plan says all the services you need are offered at the inpatient rehabilitation facility. 
Transfer to a SNF for inpatient skilled rehabilitation services 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 daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code G0483) provided on May 
10, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Healthcare Common 
Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not supported. The place of service on the 
CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an office 
setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on May 10, 2021, 
and received by the lab on May 12, 2021. It is noted multiple attempts were made to obtain additional 
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
service (CPT code G0483) provided on May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nalu PNS device (CPT code(s): L8680 x16 and 64555 
x2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Nalu PNS device in the setting of chronic 
shoulder pain have not been demonstrated in the peer-reviewed literature. The Plan states here is insufficient 
evidence in the literature and research to support the safety and effectiveness of the PNS for the treatment of 
the enrollee's condition of chronic pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/ investigational for shoulder pain. Therefore, the request is 
considered not medically reasonable or necessary. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nalu PNS device (CPT code(s): L8680 x16 and 64555 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right total knee arthroplasty. 
 
You asked the Plan to pre-approve the knee surgery. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that total knee arthroplasty is only covered for the 
indications established in the applicable LCD. 
 
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 knee surgery. Our reviewer says 
that the requested knee procedure is not medically reasonable and necessary. Our physician reviewer found that 
detailed documentation is not evident regarding radiographic evidence of advanced joint disease as the x-rays 
demonstrated mild knee arthritis. Additionally, detailed documentation is not evident regarding trial and failure 
of recent, reasonable, and comprehensive less invasive conservative care measures. There is also no evidence 
of failure of previous osteotomy; distal femur fracture; malignancy of the distal femur, proximal tibia, knee 
joint, or adjacent soft tissues; failure of previous unicompartmental knee replacement; avascular necrosis of the 
knee; or proximal tibia fracture. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception to guidelines. Therefore, the requested right 
total knee arthroplasty medically reasonable and necessary according to the coverage criteria established in the 
LCD. 
 
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 knee surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve right total knee arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home care services - personal care/consumer directed 
personal assistance services (CPT code T1019). 
 
You asked the Plan to pre-approve the services. You say that you meet criteria for skilled needs, and you 
already have a hospice nurse that comes to the home once a week and has agreed that you have a skilled need. 
The Plan denied your request. The Plan says Original Medicare does not cover personal care through Consumer 
Directed Personal Assistance Services, non-institutional (personal care at your home that can be provided by 
non-medical professions). 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. This service is not covered by Medicare or your health plan. Therefore, we decided that the Plan does not have to pre-approve home care 
services - personal care/consumer directed personal assistance services (CPT code T1019).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 23, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 76700 
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 imaging services provided to the enrollee on October 23, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 2, 2021, to May 9, 
2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital stay was 
medically necessary and met the criteria for Medicare coverage. The Plan denied your request. The Plan says 
that the inpatient hospital stay was not medically necessary, and the enrollee could have been treated in an 
observation setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was admitted on May 2, 2021, with substernal chest pain. He was evaluated 
and found to have hyper glycemia, hypokalemia, and hypomagnesemia. Electrocardiogram showed right 
bundle branch block and left atrial enlargement. He had additional complaints and was evaluated and treated by 
multiple departments. His condition stabilized and improved, and he was discharged on May 9, 2021. The 
review has determined that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 2, 2021, to May 9, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. FDA indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis including the planned level of implantation at L4-L5. FDA 
contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately 
addressed in the medical records. There is no documentation of the enrollees height, weight or body mass 
index. There is imaging evidence of mild dextrocurvature of the lumbar spine, with no documentation of the 
Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant 
osteoporosis in this enrollee. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex 
Superion interspinous device at L4-5 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 8, 2021, to November 9, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were having a 
routine colonoscopy and your physician sent you directly to the emergency room after a pre-op checkup. You 
also say your insurance should pay because this was not an unjustified procedure. 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 $120 
copayment for an emergency room visit.  
 
 
The Plan has agreed to pay this claim, but you are responsible for a portion of it. You have been asked to pay a 
$120 copayment for an emergency room visit. An emergency room visit falls within the Emergency 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 copayment for an emergency room visit provided on November 8, 2021, to 
November 9, 2021.