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

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64629 and 
64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the intracept procedure is considered unproven as its clinical value 
and effectiveness have not been demonstrated in the peer-reviewed literature and more research is needed to 
show safety and efficacy of the 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 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 and 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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code(s): 64629 and 64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does 
need some therapy, but this does not meet criteria for admission to an IRF. The Plan also says that the 
enrollee's needs could be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. Our physician reviewer also 
found that there is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with lesion removal 
performed on March 1, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were under the impression 
that the procedure was preventive. 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 $395 
copayment for surgery or procedures at an outpatient hospital.  
 
The record shows that polyps were removed during the procedure. For this reason, the colonoscopy is 
considered diagnostic. Therefore, you have been asked to pay a $395 copayment for the colonoscopy. The 
colonoscopy 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 a 
colonoscopy with lesion removal performed on March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on October 28, 
2021, to October 29, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met. Our physician 
reviewer found the enrollee was electively admitted for embolization of an aneurysm. The procedure and post-
operative course were uncomplicated and she was discharged home on October 29, 2021. The records do not 
show that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's 
necessary hospital care (including earlier emergency department and/or observation 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 pay for the acute inpatient hospital care provided on October 28, 2021, to October 29, 
2021.
Appeal type: Surgery
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 the enrollee has tried conservative treatments that 
have not worked. The Plan denied your request. The Plan says the enrollee's 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, especially given the enrollee's history of medications for a mental health diagnosis. The 
Plan states the requested procedure 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 and 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81401, 81403, 81404, 81405, 
81406, and 81479 provided on October 26, 2021. 
 
You asked the Plan to pay for the laboratory 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. 
 
We find that CPT codes 81401, 81403, 81404, 81405, 81406, and 81479 are not supported in the medical 
record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more 
genes will be considered part of the same panel. A panel constitutes a single procedural code so one code 
should be submitted for the panel. Review of the file does not support that only one code was billed for the 
panel provided. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 81401, 81403, 81404, 81405, 81406, and 81479 provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost for  the ablation therapy, echo and duplex scan provided from 
January 20, 2022, through January 31, 2022. 
 
You asked the Plan to waive the cost for ablation therapy, echo, and duplex scan.. You say that the enrollee has 
limited income and is unable to pay. The Plan denied your request. The Plan says that the cost share amounts 
have  been applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 per day, per provider, for diagnostic procedures and tests. The enrollees contract with the Plan 
also clearly says enrollees pay a $0 copayment for each Medicare-covered outpatient hospital facility visit and 
enrollees pay $0 for Medicare-covered visits with a specialist. 
 
The Plan says you must pay a deductible and coinsurance for these services. The Plan contract does not list a 
deductible that would apply to any service. Based on the Plan contract, you cannot be asked to pay more than 
$0 for surgical and diagnostic services. Therefore, we decided the Plan has to waive the cost for the 
endovenous ablation therapy, echocardiography and duplex scan provided from January 20, 2022, through 
January 31, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy services coded 44204 provided on January 5, 
2022. 
 
You asked the Plan to pay for the laparoscopy 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, we have confirmed that code 44204 
is a column II code to column I code 44140 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the laparoscopy services coded 44204 provided on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the procedure is experimental and non-covered. 
 
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 services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy. 
 
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 an Intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for eyeglasses provided on May 11, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that due to the unexpected death of your friend and 
family issues, and property issues there has been much going on. The Plan denied your request. The Plan says 
that the Plan started the $100 benefit allowance towards eyewear in 2021. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided us with documentation to show if the 
eyeglasses were provided due to a routine vision benefit or a Medicare vision benefit. The Plan has not 
provided us with the exact reason for the denial of the eyeglasses or the Plans rule to support their denial. 
Therefore, we decided that the Plan has to pay for eyeglasses provided on May 11, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level and each 
additional level (CPT code(s): 64484 and 64483). 
 
You asked the Plan to pre-approve the injections. You say that without the injections the enrollee's well-being 
and quality of life will start to decline. The Plan denied your request. The Plan says the enrollee's request is not 
medically necessary because their records do not show that it has been three months since the enrollee's last 
injection. 
 
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 injections. Our physician reviewer 
found the request does not meet the time interval required by the LCD. The pain relief report is inconsistent 
with the progress notes. The enrollee has not completed a course of Physical therapy. Therefore, the patient 
does not meet the criteria of the LCD and 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level and each additional level (CPT code(s): 64484 and 
64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services and treatment to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the health plan wants you to see 
an in-network provider that does not do as good a job as this provider you have requested. The Plan denied 
your request. The Plan says there are participating providers within the health plan that can provided the 
necessary services. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services and treatment to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper and lower bilateral extremity veins duplex scan 
provided on December 19, 2021. 
 
You asked the Plan to pay for the upper and lower bilateral extremity veins duplex scan. You say that you 
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this 
is a duplicate claim, and no additional payment is allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that claims or claim lines that have 
been determined to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. In this case, the documentation does not support additional payment 
for the services as billed beyond what has already processed for payment. Based on this information, we 
decided that Medicare rules for coverage of the upper and lower bilateral extremity veins duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for the upper and lower bilateral extremity 
veins duplex scan provided on December 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on 
March 8, 2022. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that the 
services were rendered at a separate freestanding facility and that you should only have a $100 copay. The Plan 
denied your request. The Plan says The provider would need to submit a correct claim with a freestanding 
facility listed as the location in order for the plan to adjust the appeal. 
 
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 $250 
copayment for a computerized tomography (CT) scan.  
 
You have been asked to pay a $250 copayment for a computerized tomography (CT) scan. A computerized 
tomography (CT) scan falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on 
March 8, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network (OON) psychotherapy 
services provided on November 17, 2021. 
 
You asked the Plan to waive the copayment for the OON psychotherapy services. You say that you were 
informed that the provider was in-network. 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 $55 
copayment for each therapy visit with an out-of-network provider.  
 The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $55 copayment for the OON psychotherapy services. The OON psychotherapy services fall within the 
Outpatient Mental Health 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 
out-of-network (OON) psychotherapy services provided on November 17, 2021.