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

 
We decided that the Plan does not have to pre-approve excision of excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy. 
 
You asked the Plan to pre-approve excision of excessive skin and subcutaneous tissue. 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 follows Medicare rules. Medicare rules say that excision of excessive skin is only covered for certain 
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 excision of excessive skin and 
subcutaneous tissue. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found you have a paraumbilical hernia, unspecified 
back pain, and impaired mobility. You have complaints of rash to the skin folds when the weather is hot. You 
did not endorse significant weight loss. The abdominal examination was notable for "scarring". The 
documentation does not support that you have pannus or panniculus hangs below the level of the symphysis 
pubis causing chronic intertrigo that consistently remains refractory to appropriate medical therapy over a 
period of three months and/or difficulty walking or functional impairment in activities of daily living. 
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 excision of excessive skin and subcutaneous tissue have not been met. 
Therefore, we decided that the Plan does not have to pre-approve excision of excessive skin and subcutaneous 
tissue (includes lipectomy); abdomen, infraumbilical panniculectomy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the heart, without 
contrast material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is not medically necessary. 
 
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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that the reviewed documentation indicates 
that your cholesterol is elevated despite taking the medication Zetia. It is also noted that you have not tolerated 
statins in the past and did not feel well after taking the medication for a month. Additionally, the blood testing  
showed abnormalities. An atherosclerotic cardiovascular disease risk (ASCVD) score calculation was 
performed and you were indicated as high risk. Calcium CT scoring is not necessary or helpful when there is 
already sufficient evidence that continued statin use is recommended. Given your history of statin intolerance, a 
proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitor is indicated. There is no specific clinical 
rationale for calcium CT scoring. The review has determined that the requested CT Scan of the Heart with 
quantitative evaluation of coronary calcium 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT), of the heart, without contrast material, with quantitative 
evaluation of coronary calcium (75571).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested services are experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate the 
safety and effectiveness of the device. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 heavy duty power operated vehicle (K0807). 
 
You asked the Plan to pre-approve a Group 2 heavy duty power operated vehicle. You say that the requested 
item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
a power operated vehicle have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs are not reasonable and necessary.  
 
We looked at the file and Medicare rules. The request is for a Group 2 POV. Based on this information, we 
decided that Medicare rules for coverage of a Group 2 heavy duty power operated vehicle have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 2 heavy duty power operated vehicle 
(K0807).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 22, 
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 records do not support the services billed. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
CPT 26045: 
 
Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial 
 
CPT 26340: 
 
Manipulation, finger joint, under anesthesia, each joint  
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records and operative 
note do not support the use of these two codes. There is no documentation to support them. 
 
We looked at this coder'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 pay for surgical services provided to the enrollee on October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back cane bracket (E1399) and an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary. The Plan denied your request. The Plan says upgraded electronics (electronic connection, 
expandable controller and harness) cannot be covered per Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a back cane bracket (E1399) and an electronic connection 
between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without fusion, including image guidance when performed, with open 
decompression, lumbar; single level (CPT code 22867) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without fusion, including image guidance when performed, with open 
decompression, lumbar; second level (CPT code 22868). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your records do not show that you meet the criteria for lumbar fusion or lumbar 
laminectomy because there is no record that you have tried non-operative therapy for three (3) months. 
 
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 interlaminar devices remain experimental. More research is needed.  
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 insertion of interlaminar/interspinous process stabilization/distraction device, without 
fusion, including image guidance when performed, with open decompression, lumbar; single level (CPT code 
22867) and insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, 
including image guidance when performed, with open decompression, lumbar; second level (CPT code 22868).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a percutaneous peripheral nerve 
stimulator. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this would be an experimental/investigational approach to the treatment of occipital 
neuralgia. 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation of a percutaneous peripheral nerve stimulator.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on February 19, 2021. 
 
You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). You 
say that the attached documentation should be reviewed for medical necessity and the claim should be paid. 
The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on February 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that Medicare has been covering this procedure for 
over five (5) years, please approve the enrollee to have this procedure performed. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment to be provided by the requested 
provider. 
 
You asked the Plan to pre-approve acupuncture treatment. You say that you were approved last year for the 
services. The Plan denied your request. The Plan says this provider is not a Medicare-participating practitioner, 
eligible to bill for services nor does the provider perform services under the direct supervision of a Medicare-
participating practitioner eligible to bill for services. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, physician 
assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to 
pre-approve acupuncture treatment to be provided by the requested provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis to be provided by the requested out-of-network 
provider.  
 
You asked the Plan to pre-approve dialysis to be provided by the requested out-of-network provider. You say 
that long distances will not be beneficial to member due to her history of bleeding and because she is 
bedridden. The Plan denied your request. The Plan says the Plan has a contracted provider that can offer the 
service within a reasonable distance and timeframe. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve dialysis to 
be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 25, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were in agonizing pain due to a pinched nerve 
and had to have relief other than pain killers. You say that you could end up paralyzed with a regular spinal 
adjustment and the claim should be reconsidered. The Plan denied your request. The Plan says Medicare does 
not cover office visits from a chiropractor. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on February 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 17, 
2022. 
 
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 Medicare does not separately for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) provided on March 9, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 drug testing (G0482) provided on March 9, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307) provided on February 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 drug testing (80307) provided on February 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a primary care telehealth visit provided on 
December 8, 2021. 
 
You asked the Plan to waive the deductible for the telehealth visit. You say that you want your deductible 
moved to your new plan. The Plan denied your request. The Plan says the correct amount was 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 $250 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $250 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the telehealth visit was received on 
December 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a primary 
care telehealth visit provided on December 8, 2021.