Persius/hicric huggingface dataset:
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 disagree with the 
Plan's 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 the enrollee was being treated for spinal stenosis of the lumbar region 
with neurogenic claudication. The enrollee presented with lumbar pain that is sharp, burning, shooting, and 
stabbing. The pain is rated at eight out of 10. The symptoms have not improved. The exam reveals limited 
range of motion with pain. There is tenderness to palpation in the bilateral L4-S1 paraspinals. The facet loading 
is positive bilaterally. However, 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 specific medical condition.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for chiropractic care on January 24, 2022, to 
May 02, 2022. 
 
You asked the Plan to waive the deductible for chiropractic care. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 a $1,500 deductible which applies to Chiropractic services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Chiropractic 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 
deductible which applies to Chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time chiropractic care was received on January 14, 2022, to May 2, 2022. Therefore, we decided that 
the Plan does not have to waive the deductible for chiropractic care on January 24, 2022, to May 02, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on June 02, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $30 
copayment for provider and professional services at specialists office. Covered services include consultation, 
diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $30 copayment for office visit. Office 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 waive the copayment 
for office visit on June 02, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a self-administered drug provided from March 24, 2022, to 
March 27, 2022. 
 
You asked the Plan to pay for a self-administered drug. The Plan denied your request. The Plan says self-
administered drugs are not covered under Part B of Original Medicare; therefore, they are not covered under 
the medical benefits for members of our Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for a self-administered drug 
provided from March 24, 2022, to March 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intercept Procedure. 
 
You asked the Plan to pre-approve Intercept Procedure. You say that you disagree with the Plan's 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 Intercept Procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for spondylosis without myelopathy or radiculopathy 
of the lumbosacral region and low back pain. The enrollee presented with low back and right lower extremity 
pain. The enrollee centralized the worst of the pain to the left low back. The pain is a dull ache. Leaning 
forward exacerbates this pain. The enrollee has numbness on the lateral aspect of the right thigh but denies any 
radiating pain in the bilateral lower extremities. The exam reveals limited forward flexion with mild pain. 
There is mild pain with extension. In this case, there were/are multiple plausible pathologic sources of 
significant pain generation. Despite reported non-radiating midline back pain, there are plausible radicular 
findings including thigh numbness. These findings (along with the diminished and painful spinal motion) were/are all non-specific to any pathologic entities. The documentation does not support actual formal surgical 
ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. 
Therefore, the enrollee does 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 Intercept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Intercept Procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgical supplies on March 30, 2022. 
 
You asked the Plan to waive the coinsurance for surgical supplies. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 20% 
coinsurance for each Medicare-covered medical supply. Covered services include but are not limited to surgical 
supplies, such as dressings. The provider billed in the amount of $25,665.32 and the allowed amount is 
$5,143.38. $5,143.38 x 20% = $1,028.68. Therefore, results in the total cost sharing amount of $1,028.68. 
 
You have been asked to pay a 20% coinsurance for surgical supplies. Surgical supplies fall within the 
Outpatient diagnostic test and therapeutic services and supplies 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 coinsurance for surgical supplies on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection on November 18, 2021. 
 
You asked the Plan to waive the coinsurance for injection. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 20% 
coinsurance for injections or durable medical equipment and prosthetic/orthotics if supplied by the physician, 
in addition to office visit copay Physician/Practitioner services, including doctor's office visits. Covered 
services include medically-necessary medical care or surgery services furnished in a physicians office, 
certified ambulatory surgical center, hospital outpatient department, or any other location. The provider billed 
in the amount of $265 and the allowed amount is $77.45. $77.45 x 20% = $15.49. Therefore, results in the total 
cost sharing amount of $15.49. 
 
 
 You have been asked to pay a 20% coinsurance for injection. Injections 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 waive the coinsurance 
for injection on November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiogram provided on April 11, 
2022. 
 
You asked the Plan to waive the copayment for an echocardiogram. You say that you already paid a copayment 
related to this service and feel you should not have to pay another. The Plan denied your request. The Plan says 
the copayment that was applied was correct. 
 
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 $75 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $64.96, which is less than the $75 copayment for an 
echocardiogram. An echocardiogram falls within the Outpatient Diagnostic Tests And Therapeutic Services 
And Supplies 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 echocardiogram provided on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a health-club membership (S9970). 
 
You asked the Plan to pre-approve a health-club membership. You say that the requested service is a medical 
necessity for you as prescribed by your primary care physician. The Plan denied your request. The Plan says 
rules for coverage for health-club benefits have not been met. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when obtained through participating providers. 
 
The Plans rules for coverage of gym benefits have not been met because the requested health club is not a 
participating provider. Therefore, we decided that the Plan does not have to pre-approve a health-club 
membership (S9970).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 24, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 ambulance services provided on December 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2022 to March 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this code is separately payable. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2022 to March 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve diagnostic MBBs. You say that you need surgery due to abnormal findings 
on radiological readings and cervical spine pain. The Plan denied your request. The Plan says the requested 
services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that injection services are only covered when there is an 
absence of untreated radiculopathy or neurogenic claudication and there is no non-facet pathology per clinical 
assessment or radiology studies that could explain the source of the patients pain, including but not limited to 
fracture, tumor, infection, or significant deformity. 
 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 diagnostic MBBs. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found you have chronic neck pain and scolosis of the cervical and thoracic spines. You 
have radicular pain that starts in your neck and radiates to your fingers. You have had medication trials, 
Physical therapy and transcutaneous electrical nerve stimulation (TENS). Imaging shows facet arthropathy but 
also disc space narrowing at C4-C5 and C5-C6. You have radicular symptoms of pain radiating into your 
fingers and you have scoliosis of the cervical and thoracic spine. Therefore, you do not meet the criteria for 
facet injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic MBBs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve diagnostic medial branch blocks (MBBs).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 1, 2021 to April 30, 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 has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of skilled nursing facility (SNF) services 
provided to the enrollee from April 1, 2021 to April 30, 2021. have been met. There appears to be insufficient 
documentation found in the medical records to support the enrollee's usual functional abilities during the 
collection period. Most of the data was not provided during the covered three day collection period, which 
would be March 26, 2021, March 27, 2021, or March 28, 2021.. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from April 1, 2021 to April 30, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 12, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 ambulance services provided on December 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 30, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the member 
was in hospice on this date of service. 
 
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 physician's services provided on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on March 22, 2022. 
 
You asked the Plan to pay for code 0013M. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0013M) provided on March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of ILR. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary].***} 
 
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 insertion of ILR. Our reviewer says that 
the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee had no history of atrial fibrillation, nor were any significant cardiac 
arrhythmias noted on electrocardiogram monitoring. A recent randomized clinical trial found that continuous 
monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial 
fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
enrollees at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of implantable loop recorder (ILR).