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

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
22, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you had a side effect to 
the medicine you were taking, and you weren't aware that could happen. The Plan denied your request. The 
Plan says you were charged this cost sharing correctly. 
 
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 $ 275 
copayment for each ambulance trip. You had one ambulance trip(s). The Plan charged you $275 for these 
services. 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 the ambulance services provided on May 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extra-spinal manipulation (98943), therapy technique 
(97530), and mechanical traction (97012) provided on April 20, 2022. 
 
You asked the Plan to pay for the manipulation, therapy technique, and traction. You say that you were given 
incorrect information about your chiropractor visits. The Plan denied your request. The Plan says you reached 
your maximum enhanced chiropractic services on your March 28, 2022, visit. 
 
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 Plan offers a chiropractic benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 We looked at your request, the file, and rules. Based on this information we have determined that criteria for 
payment have not been met. Though the Plan offers a chiropractic benefit in excess of Medicare coverage, 
certain limitations apply. The record shows your benefit for the requested item or service was exhausted on 
date of service March 28, 2022. Therefore, we decided that the Plan does not have to pay for extra-spinal 
manipulation (98943), therapy technique (97530), and mechanical traction (97012) provided on April 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the Intracept 
procedure in the setting of vertebrogenic low back pain have not been demonstrated in the peer-reviewed 
literature. 
 
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. More research is needed to show safety and 
efficacy of the procedure. 
 
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 (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertilfex procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93313 billed for date of service December 
21, 2021. 
 You asked the Plan to pay for procedure code 93313. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 93313 is bundled into payment for code 00567. 
 
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 93313 
is a column II code to column I code 00567. 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 93313 billed for date of service December 21, 
2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wireless capsule endoscopy. 
 
You asked the Plan to pre-approve wireless capsule endoscopy. 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 follows Medicare rules. Medicare rules say that wireless capsule endoscopy of the small bowel is 
considered medically reasonable and necessary when specific criteria are met. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found available records do 
not support there being occult gastrointestinal (GI) bleeding, high suspicion of Crohn's disease, nor is 
intraoperative enteroscopy planned. No lab data was supplied for this review to evidence ongoing unexplained 
anemia. Recent upper GI endoscopy (EGD) findings have determined the likely cause of the enrollee's 
abdominal pain and subjective weight loss. Medical necessity is not demonstrated in this case, and at this time, 
for the requested wireless capsule endoscopy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve wireless capsule endoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extra-spinal manipulation (98943) and therapy technique 
(97530) provided on April 15, 2022. 
 
You asked the Plan to pay for the manipulation and therapy technique. You say that you were given incorrect 
information about your chiropractor visits. The Plan denied your request. The Plan says you reached your 
maximum enhanced chiropractic services on your March 28, 2022, visit. 
 
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 Plan offers a chiropractic benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 We looked at your request, the file, and rules. Based on this information we have determined that criteria for 
payment have not been met. Though the Plan offers a chiropractic benefit in excess of Medicare coverage, 
certain limitations apply. The record shows your benefit for the requested item or service was exhausted on 
date of service March 28, 2022. Therefore, we decided that the Plan does not have to pay for extra-spinal 
manipulation (98943) and therapy technique (97530) provided on April 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting long term acute care 
hospital admission. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve this equipment. You say that this equipment is medically necessary. The 
Plan denied your request. The Plan says you have had a Trilogy device but are not using the device 
consistently. Your records show that you used the device for more than 4 hours a day only 26.3% of the days 
over the past 2 years. For 73.7% of the days between August 5, 2020, to June 8, 2022, you used the device less 
than 4 hours a day. Additionally, your records say that you only used the device 73% of days in total; there 
were 181 days in the past year where you did not use the device at all. 
 
The Plan must follow Medicare rules. The rules the medical records must show a ventilator is medically 
necessary. The records show you have a similar type of equipment that you are not compliant with.  
Based on this information, we decided that Medicare rules for coverage of this equipment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on January 
27, 2022. 
 
You asked the Plan to pay for the critical care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records 
submitted did not include a critical care visit of 30-74 minutes was performed. The records did not include the 
time spent providing this service. Based on this information, we decided that Medicare rules for coverage of the 
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care services coded 99291 provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extra-spinal manipulation (98943), therapy technique 
(97530), self-care/home management training (97535), and an office visit (99203) provided on April 27, 2022. 
 
You asked the Plan to pay for the manipulation, therapy technique, management training, and office visit. You 
say that you were given incorrect information about your chiropractor visits. The Plan denied your request. The 
Plan says you reached your maximum enhanced chiropractic services on your March 28, 2022, visit. 
 
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 Plan offers a chiropractic benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 We looked at your request, the file, and rules. Based on this information we have determined that criteria for 
payment have not been met. Though the Plan offers a chiropractic  benefit in excess of Medicare coverage, 
certain limitations apply. The record shows your benefit for the requested item or service was exhausted on 
date of service March 28, 2022. Therefore, we decided that the Plan does not have to pay for extra-spinal 
manipulation (98943), therapy technique (97530), self-care/home management training (97535), and an office 
visit (99203) provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve CPAP device. You say that you are having trouble sleeping and your 
provider recommended a CPAP device. The Plan denied your request. The Plan says there is no clinical 
evidence to support the medical necessity of this the device or that you meet Medicare criteria. 
 
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 CPAP device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found continued coverage of a CPAP is not medically necessary because usage of the device is not 
sufficient for clinical benefit. You have OSA and CPAP was prescribed 2/16/2022. Usage data 4/6/22 to 
7/4/2022 showed only 11% of days the device was used at least 4 hrs./day, which does not meet minimum 
Medicare requirement of at least 70% of days. There is no subsequent clinical visit to address compliance 
issues. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64625 billed for date of service November 
18, 2021. 
 
You asked the Plan to pay for procedure code 64625. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the submitted records do not show evidence of 
code 64625 being performed. There is a more appropriate code to describe the services documented as 
endoscopic rhizotomy. 
 
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 64625 is Radiofrequency ablation, nerves innervating the 
sacroiliac joint, with imaging guidance (Fluoroscopic or Computed Tomography). 
 
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 procedure code 64625. Our reviewer says that code 64625 is not supported by the medical record. Our reviewer found the operative report describes "Rhizotomy of the right 
L5, S1 and S2 lateral branches". In this case, there is a more appropriate code set to report for service 
provided.  This procedure was billed incorrectly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64625 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64625 billed for date of service November 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you will benefit from more physical therapy. You 
live alone currently and have impairment. The Plan denied your request. The Plan says criteria for admission to 
a SNF have not been met. Skilled services can be provided on an intermittent outpatient basis, in a long-term 
care facility, or at the home with home health care services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim and that the services provided were medically necessary. The Plan denied your request. The Plan 
says the provider is out-of-network, and it was determined these services were 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 laboratory services provided on May 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extra-spinal manipulation (98943) and therapy technique 
(97530) provided on April 11, 2022. 
 
You asked the Plan to pay for the manipulation and therapy technique. You say that you were given incorrect 
information about your chiropractor visits. The Plan denied your request. The Plan says you reached your 
maximum enhanced chiropractic services on your March 28, 2022, visit. 
 
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 Plan offers a chiropractic benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 We looked at your request, the file, and rules. Based on this information we have determined that criteria for 
payment have not been met. Though the Plan offers a chiropractic benefit in excess of Medicare coverage, 
certain limitations apply. The record shows your benefit for the requested item or service was exhausted on 
date of service March 28, 2022. Therefore, we decided that the Plan does not have to pay for extra-spinal 
manipulation (98943) and therapy technique (97530) provided on April 11, 2022.