Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back pain pump for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says unfortunately, this request cannot be approved by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a preliminary trial of intraspinal opioid or non-
opioid drug administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate 
acceptable pain relief, degree of side effects including effects on the activities of daily living, and patient 
acceptance and compliance.  
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this request is premature. A trial of intra-thecal narcotics must be performed first and if successful, then 
the permanent pump implant can be performed.  At this point, the request 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a back pain pump for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebroplasty. 
 
You asked the Plan to pre-approve percutaneous vertebroplasty. The Plan denied your request. The Plan says 
the coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty is 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 percutaneous vertebroplasty. Our 
reviewer says that the requested percutaneous vertebroplasty is not medically reasonable and necessary in this 
case. Our physician reviewer found that the coverage criteria have not been met as the compression fracture 
would not be considered acute or subacute (as it has been longer than 12 weeks since the fall was noted on 
January 9, 2022). Additionally, the pain scale rating was not noted on the exam. Regardless, the MRI 
demonstrated subacute L1 compression fracture, with 70% loss of vertebral body height and 6mm bony 
retropulsion. The latter represents a relative contraindication for the requested procedure. Therefore, the 
enrollee, in this case, does not meet all of the coverage criteria in the above LCD for coverage of the requested 
percutaneous vertebroplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous vertebroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1851). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as the enrollee has 
had several instances of rotational instability. The Plan denied your request. The Plan says the records do not 
show recent injury 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found knee instability has not been documented on examination. There has not been any recent injury or 
surgery to the knee. 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 knee orthosis 
(L1851) 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1851).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for wound care. You say that this was provided in a wound clinic 
but is being charged for outpatient surgery. The Plan denied your request. The Plan says the copayment applied 
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 $325 
copayment for each Medicare covered outpatient hospital facility visit.  
 
You have been asked to pay $138.81 which is less than the $325 standard copayment for wound care. Wound 
care falls within the Outpatient surgery including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 wound care 
provided on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous glucose monitor (CGM) 
supplies provided on March 2, 2022. 
 
You asked the Plan to waive the coinsurance for the CGM supplies. You say that the supplies were covered 
previously and would like them covered now. 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 durable medical equipment (DME), including CGM supplies for any device other that the 
Freestyle Libre.  
 
The record shows your device is a Dexcom. Therefore, you have been asked to pay $140.76, which is 20% of 
the allowed amount for the CGM supplies. The CGM supplies fall within the Durable Medical Equipment 
(DME) 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 continuous 
glucose monitor (CGM) supplies provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on December 21, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that service provided to the enrollee was out of 
medical necessity due to the enrollee's condition. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 the outpatient services provided on December 21, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder arthroscopy (procedure code 29826) provided to the 
enrollee on October 25, 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 code 29826 is "Arthroscopy, shoulder, surgical; 
decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) 
release, when performed (List separately in addition to code for primary procedure)." 
 
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 the records do support CPT 29826: 
arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with 
coracoacromial ligament (ie arch) release, when performed (list separately in addition to code for primary procedure)- was rendered in this case. The enrollee was being treated for complete rotator cuff tear or rupture 
not specified as traumatic; primary osteoarthritis of the left shoulder; chondromalacia of the left shoulder; and 
other specific disorders of tendon, left shoulder. He underwent a diagnostic arthroscopy of the left shoulder; 
long head biceps tenotomy; superior capsular reconstruction; labral tear; release of coracoacromial (CA) 
ligament; and acromioplasty on 10/25/21. The procedure note indicates that a limited subacromial 
decompression was also performed to minimize the risk of graft rupture. (CA ligament release is inherent in 
such a procedure, based on its anatomical location). Therefore, the records do support CPT 29826 in this case. 
 
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 shoulder arthroscopy (procedure code 29826) provided to the enrollee on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles (K0108). 
 
You asked the Plan to pre-approve push handles. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says the push handles do not serve a medical purpose and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of push handles have not been met. Therefore, we decided that the Plan does not have to pre-approve 
push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 18, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
October 18, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided November 16, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in addition to single gene testing, panels that 
include the FANCC genes are statutorily excluded service. 
 
We looked at the file and Medicare rules. This panel included testing for the FANCC genes. Panels that 
included this testing are statutorily excluded from coverage. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (0037U) provided November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam and eye ultrasound provided 
on February 16, 2022. 
 
You asked the Plan to waive the copayment for an eye exam. You say that you get one free glaucoma exam a 
year. 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 $45 
copayment for an exam to diagnose and treat diseases or conditions of the eye.  
 
The record shows you were seen for services related to the diagnose or treatment of an eye condition. You have 
been asked to pay a $45 copayment for an eye exam. An eye exam falls within the Vision 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 eye exam and eye ultrasound provided on 
February 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicty. 
 
You asked the Plan to pre-approve Trulicty. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 pre-approve Trulicty.  
 
Benefits for Trulicty 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
February 24, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that your doctor would not see you and 
referred you to the ER. 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 $65 
copayment for an in-network emergency room visit.  
 
You have been asked to pay a $65 copayment for an ER visit. An ER 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 (ER) visit 
provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01480 provided on November 
2, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as 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 code 01480 is anesthesia for open procedures on bones of 
lower leg, ankle, and foot; not otherwise specified. 
 
We find that CPT code 01480 is not supported in the medical record. Specifically, this service was billed with a 
manifestation diagnosis code as the primary diagnosis. Manifestation diagnosis codes cannot be billed as a 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 01480 provided on November 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a paravalvular leak closure. 
 
You asked the Plan to pre-approve a paravalvular leak closure. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a paravalvular leak closure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found randomized controlled trials have not confirmed the clinical efficacy of this 
technique compared with conventional treatment. Thus, the technique is considered investigational. As a result, 
at this time transcatheter paravalvular leak closure (TPVLC) would not be considered medically reasonable 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 a paravalvular leak closure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a paravalvular leak closure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve above the knee alignable system (L5920). 
 
You asked the Plan to pre-approve above the knee alignable system. You say that the requested prosthetic 
equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested above the knee alignable system is not medically reasonable and necessary based on the enrollee's 
functional status. 
 
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 above the knee alignable system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 59-year-old male with an acquired absence of the left leg 
above the knee, currently approved for a prosthetic device. In this case, the requested above the knee alignable 
system exceed the patient's medical need as the patient current approved preparatory prosthesis is non-alignable 
and at this time the alignable system is not appropriate for the patient's functional level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of above the knee alignable system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve above the knee alignable system (L5920).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record does not show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital 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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.