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

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is contraindicated for the enrollee. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service January 9, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
January 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on October 
17, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). The Plan denied your request. The Plan 
says procedure code 01230 has been paid and procedure code 99100 remains denied as bundled services are not 
eligible for separate reimbursement.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on October 17, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the Positron Emission Tomography (PET) scan, provided on November 
29, 2021. 
 
You asked the Plan to pay for the PET scan. You say that the service was medically necessary. The Plan denied 
your request. The Plan says that the service was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the PET scan. Our reviewer says that the 
service was medically necessary. Our physician reviewer found while it is true the computerized tomography 
(CT) scan was stable between May 20, and March 21, adenocarcinoma of the lung can be a slow growing 
process. Rather than repeat a CT 6 months after the last CT it was reasonable to do a PET scan to analyze the 
metabolic activity of the multitude of abnormal findings on the CT in order to assess any need for change in 
treatment. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pay for 
the Positron Emission Tomography (PET) scan, provided on November 29, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes and custom shoe inserts. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic shoes and custom shoe 
inserts.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on December 
14, 2021. 
 You asked the Plan to pay for the CT scan. You say that the procedures have been coded per guidelines. The 
Plan denied your request. The Plan says an appropriate modifier was not 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 70450 is a column II code to column I code 70496. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scan provided on December 14, 2021.
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. You say that IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says IRF admission is not medically necessary and the 
enrollee's needs can be safely met in a less intensive setting such as at home with supervision and home health 
services, in an assisted living facility with home health services, or in long-term care with part-time skilled 
services. 
 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 that while the enrollee may benefit from physical therapy and occupational therapy, 
his rehab needs can be addressed at a low intensity alternate setting such as in a skilled nursing facility. 
 
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: 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. You say that IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says IRF admission is not medically necessary and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 that while the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program such as 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation that can accommodate a 
gurney. 
 
You asked the Plan to pre-approve the non-emergency transportation. The Plan denied your request. The Plan 
says non-emergency medical transportation (NEMT) requires the completion of a physician certification 
statement (PCS) form to determine the appropriate level of service. The Plan also says that a PCS has been 
unable to be obtained from your physician despite multiple attempts. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of non-emergency transportation that can 
accommodate a gurney have been met. The Plan has made multiple attempts to request a physician certification 
statement (PCS) from your provider, which is a requirement, and it has not been received. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency transportation that can accommodate a 
gurney.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant supported porcelain/ceramic crowns 
(D6065). 
 
You asked the Plan to pre-approve the implant supported crowns. You say that this service is necessary as 
without implants your health is deteriorating. The Plan denied your request. The Plan says this service is not 
covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
implant supported porcelain/ceramic crowns (D6065).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81479) provided November 
23, 2021. 
 
 
 You asked the Plan to pay for the GeneSight Psychotropic test. You say that the combinational approach has 
been evaluated in multiple clinical studies and GeneSight is the only psychiatric pharmacogenomic test backed 
by such extensive research. The Plan denied your request. The Plan says the service does not 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the GeneSight Psychotropic test have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneSight Psychotropic test (81479) provided November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the claim has not been billed in 
accordance with Medicare coding regulations. 
 
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 laboratory 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 the laboratory services provided on July 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee does not 
have transportation to her dialysis appointments. The Plan denied your request. The Plan says that the enrollee 
has exhausted this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the items are medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stress echocardiography (ECG). 
 
You asked the Plan to pre-approve a stress ECG. You say that your condition recently regressed. You also say 
that you need this test to make sure that no further action is requested. The Plan denied your request. The Plan 
says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that stress echocardiography used as a screening test for 
ischemic heart disease in a patient without signs or symptoms 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 a stress ECG. Our reviewer says that 
the requested stress ECG is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that you have chest pain. The reviewer found that your pre-test probability for an abnormal test is low and there is no documentation that the ECG shows an uninterpretable pattern. There is no evidence 
provided that would support the need for stress echocardiography. In summary, there is insufficient 
documentation to support the medical necessity for the requested stress echocardiography in your 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 stress ECG have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a stress echocardiography (ECG).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve consultation services. You say that these services are medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there are in-network providers 
available to treat the enrollee's condition. 
 
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 
consultation services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for subsequent hospital care (99232) provided on January 3, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that this service was billed appropriately and 
is supported in the record. The Plan denied your request. The Plan says that this claim either has missing or 
incomplete information or was billed with the wrong code. 
 
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. The Plans denial is not supported in this case. Specifically, the Plan does not 
clearly state the reason for the denial in this case. The Plan also did not provide clear evidence or a specific 
citation to substantiate any reason for this denial. Therefore, we decided that the Plan has to pay for subsequent 
hospital care (99232) provided on January 3, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from August 27, 2021, 
to August 30, 2021. 
 
You asked the Plan to pay for the provided drugs. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The drugs provided during outpatient care are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from August 27, 2021, to August 30, 2021.  
 
Benefits for the provided drugs 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the member does not use insulin with at least three daily injections and 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
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 the enrollee does not use insulin 
with at least three daily injections and 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 the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).