Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the substance detoxification admission. 
 
You asked the Plan to pre-approve the substance detoxification admission. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee does not have a medical condition that 
would make the enrollee's withdrawal harder to manage. The Plan states the enrollee's withdrawal needs can be 
managed outside of a hospital. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 substance detoxification admission. 
Our physician reviewer found based upon review the records provided for the admission of this enrollee does 
not meet criteria for acute inpatient mental health/detoxification treatment as this patient was not shown to be a 
danger to themselves or others, no auditory or visual hallucinations. The enrollee is noted to be cooperative and 
compliant with treatment while not showing any aggressive behaviors. 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 
substance detoxification admission have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the substance detoxification admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee has been diagnosed with lumbar 
spinal stenosis. The Plan states the clinical recommended an interspinal spacer for the lumbar spinal stenosis 
after conservative measures failed. The Plan denied your request. The Plan says given the enrollee's diagnoses 
of mild spinal stenosis, risk for osteoporosis and lack of improvement in the enrollee's pain with flexion, this 
device is contraindicated for the enrollee. The Plan states until its efficacy (or safety for the enrollee) has been 
established, the Plan cannot approve. 
 
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(s): 22869 and 22870).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the pelvis, with 
and without dye, (72197). 
 
You asked the Plan to pre-approve an MRI. You say that the enrollee needs this test. The Plan denied your 
request. The Plan says the provided documentation does not support that the requested MRI is medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found the provided records did not clearly 
show the indication for imaging. The reviewer found there were no provided result of a prostate biopsy or other 
signs or symptoms requiring MRI of the pelvis. Therefore, without sufficient support made in the provided 
documentation, the reviewer found that the request for MRI will be considered not medically necessary at this 
time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) of the pelvis, with and without dye, (72197).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM and supplies. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the 
requested device. 
 
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 you do not require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of a FreeStyle Libre CGM and supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) and 
supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (L1843). 
 You asked the Plan to pre-approve the orthosis. You say that according to the doctors notes the brace is needed 
due to the enrollee being a poor candidate for surgery due to her other medical conditions. The Plan denied 
your request. The Plan says the request is not medically necessary because your records show you do not have 
recent injury or surgery or objective evidence of instability 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the records indicates that the enrollee has osteoarthritis. The record does not 
indicate the presence of knee instability or recent injury or surgery. The elements of the coverage criteria are 
not satisfied, and the requested service is not recommended. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee orthosis (L1843).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 procedure code 70544 billed for date of service February 24, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that this procedure improves the quality of 
life of patients suffering from vertebrogenic low back pain. The Plan denied your request. The Plan says your 
request is not medically necessary because there is little evidence in the medical literature to suggest that this is 
an appropriate procedure for the enrollee's back pain. The Plan states it is not an accepted standard of medical 
practice for the diagnosis or treatment of back pain and it is considered experimental and investigational. The 
Plan states this procedure is not indicated in the setting of central canal stenosis and osteoporosis. 
 
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 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 the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laboratory services provided on April 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and laboratory services. You say that you did not know you 
needed a referral from primary care doctor. You also say that you do not know what you need to do to get this 
claim paid. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. 
The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. The Plan also says that there is not a referring provider. 
 
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 an office visit and laboratory services provided on 
April 25, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tilting shower chair. 
 
You asked the Plan to pre-approve a tilting shower chair. You say that the tilting chair is medically necessary 
and not a convenience item. You also say you need this for your safety. The Plan denied your request. The Plan 
says the requesting shower chair is a comfort or convenience item and not primarily medical in nature. The 
shower chair is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a tilting shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 31, 2022, to April 7, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you already paid the copayment 
from another hospital stay within 90 days. 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 $100 per 
day for days 1-4 and $0 per day for days 5-90 for each inpatient admission.  
 
The file shows that you were in the hospital from March 31, 2022, to April 7, 2022. Therefore, you have been 
asked to pay $100 per day for days 1-4 of inpatient care. The total for your stay is $400 ($100 copayment x 4 
days = $400). The inpatient care falls within the Inpatient Hospital Care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from March 31, 2022, to April 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says the requested supplies are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis (back brace) 
provided on November 11, 2020. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that the provider informed you that 
there would be no cost for the brace. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 prosthetic devices and supplies, including braces.  
 
You have been asked to pay $161.50, which is 20% of the allowed amount for the back brace ($807.50 allowed 
amount x 20% coinsurance = $161.50). The back brace falls within the Prosthetic Devices and Related 
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 a lumbar-sacral orthosis 
(back brace) provided on November 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on April 24, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 magnetic resonance imaging (MRI) provided on 
April 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (CPT code 64628). 
 
You asked the Plan to pre-approve the service. You say that this procedure fills a treatment gap for those 
patients that do not receive adequate relief from traditional conservative methods. You state the enrollee has 
tried and failed conservative treatment without relief. The Plan denied your request. The Plan says your request 
is not medically necessary because there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for the enrollee's back pain. The Plan states it is not an accepted standard of medical 
practice for the diagnosis or treatment of back pain and it is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. 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. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; 
first 2 vertebral bodies, lumbar or sacral (CPT code 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the commode chair and liners provided on December 16, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the commode chair and liners. You say that your physical therapist 
recommended this commode for your recovery.  You said that you do not think it is fair that you have to wait to 
get authorization for this item. The Plan denied your request. The Plan says you did not have authorization to 
purchase these items from an out-of-network vendor.  Further, the medical records do not support that this item 
was prescribed for you. 
 
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 provider in this case is not a network provider with the Plan. 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 the commode chair and liners provided on December 16, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization to treat the enrollee's 
symptoms resulting from an enlarged prostate (CPT code 37242). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this procedure is being requested to treat the enrollee's enlarged prostate; however, there 
is very limited medical data that shows this treatment is safe and helpful in the long term. The Plan states there 
is not enough data to support the safety and helpfulness of this procedure.  
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 the medical records provided do not meet the requirements listed in the NCD for Medicare 
coverage. Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic 
benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and 
efficacy. The most recent American Urological Association (AUA) guidelines do not recommend this 
procedure outside of a clinical trial setting due to the heterogeneity in the available literature and safety 
concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, 
higher clinical failure rate compared with more traditional methods (eg, transurethral resection of the prostate 
[TURP], and adverse events. 
 
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 prostate artery embolization to treat the enrollee's symptoms resulting from an enlarged 
prostate (CPT code 37242).