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 64628). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 documentation was/is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested intracept intraosseous basivertebral nerve ablation at L5 and S1 levels, in 
this case, 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal stimulator implant (63650, 77003, 95972, 
95971). 
 
You asked the Plan to pre-approve the spinal stimulator implant. You say that the stimulator implant is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are covered when the 
implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain; when other treatment modalities (pharmacological, surgical, physical, or psychological 
therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for 
the given patient. 
 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 spinal stimulator implant. Our 
reviewer says that the requested nerve stimulator is not medically necessary. Our physician reviewer found the 
enrollee has not had any surgical treatments. The patient does not have an evidence-based indication for a 
spinal cord stimulator trial. 
 
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 spinal stimulator implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal stimulator implant (63650, 77003, 95972, 95971).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on April 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that it was medically necessary for the patient to 
receive the treatment by the provider, and you did not know that the facility failed to get pre-authorization for 
this patient, so the patient was treated anyway. The Plan denied your request. The Plan says the enrollee must 
receive care from a network provider 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for podiatry services provided on April 27, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plans network) will not be covered. 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a virtual office visit provided on June 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a virtual office visit. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee must receive care from a network provider 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a virtual office visit provided on June 27, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on March 22, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that this should be a $0 copayment under 
your vision care benefit. The Plan denied your request. The Plan says this cost sharing was charged 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 20% of 
the cost for Medicare Part B chemotherapy drugs and other Part B drugs.  
 
 
 
 The record shows this claim was approved, and you are responsible for a cost-sharing amount. You have been 
asked to pay $373.63, which is 20% coinsurance of the allowed amount for an injection ($1,868.13 x 20% 
coinsurance = $373.63). This item/service falls within the Medicare Part B prescription drugs 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 an injection provided on March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex superion implant. 
 
You asked the Plan to pre-approve Vertiflex superion implant. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 Vertiflex superion implant. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has low back pain. The Vertiflex device is experimental. More 
research is needed. Therefore, the enrollee does not meet criteria for the requested 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 Vertiflex superion implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Vertiflex superion implant.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs recondition and is motivated and 
ready to go home. You say that the enrollee was independent prior being in the hospital and is not able to go to 
a nursing home.The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
the enrollee could receive care in another setting. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided from February 
1, 2022, to February 21, 2022. 
 
You asked the Plan to pay for the provided services. You say that the enrollee was treated for post-surgical 
edema. The Plan denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.   
 
The file shows that a high-pressure pneumatic compression device (E0675) was provided. We looked at the file 
and Medicare rules. The rules say that claims for E0675 will be denied as not reasonable and necessary. 
Furthermore, the records do not show that the enrollee has met the requirements of a pneumatic compression 
device for the treatment of lymphedema. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic 
compression device provided from February 1, 2022, to February 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 documentation was/is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested intracept intraosseous basivertebral nerve ablation at L4 and L5 vertebral 
bodies, in this case, 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 20, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this shouldnt be such a high 
copayment based on where the surgery took place. The Plan denied your request. The Plan says this cost 
sharing was charged 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 Outpatient surgery. 
 
You have been asked to pay a $275 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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 outpatient surgery 
provided on April 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ground ambulance service provided on 
April 23, 2022. 
 
You asked the Plan to waive the copayment for ground ambulance service. You say that you were under the 
impression there would only be one copayment and that you did not have a choice as to where you were going 
for treatment. The Plan denied your request. The Plan says this cost sharing was charged 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 $350 per 
one-way trip for Medicare-covered ambulance services.  
 
You have been asked to pay $350 for ground ambulance service. This item/service falls within ambulance 
services 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 ground ambulance service 
provided on April 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for outpatient radiologic diagnostic services
with contrast provided to the enrollee on March 01, 2022, in the amount of $93.72.
You asked the Plan to waive this cost share. You say that you do not believe this bill is correct. The Plan
denied your request. The Plan says this cost sharing was charged correctly. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that there is a $150 copayment for outpatient
diagnostic services.
The outpatient diagnostic swallow test is not an x-ray. The enrollee was charged less than the normal
copayment expectation of $150 for these services. The enrollee was asked to pay the correct amount based on
the claim submitted by the provider and the contract with the Plan. This cost sharing is a contractual obligation
the enrollee agreed to pay when upon enrollment in the Plan. Therefore, we decided that the Plan does not have
to waive the $93.72 cost share for radiologic diagnostic services with contrast provided on March 01, 2022, to
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says it is very important to get a written referral (approval in advance) from the 
enrollees primary care provider (PCP) before the enrollee sees a plan specialist or certain other providers 
(there are a few exceptions, listed in Section 2.2 above). If the enrollee does not have a written referral 
(approval in advance) before they get services from a specialist, the enrollee may have to pay for these services 
their self. 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on December 14, 
2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that this should be a $0 copayment under 
your vision care benefit. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
 The record shows this claim was approved, and you are responsible for a cost-sharing amount. You have been 
asked to pay $374.52, which is 20% coinsurance of the allowed amount for an injection ($1,872.62 x 20% 
coinsurance = $374.52). This item/service falls within the Medicare Part B prescription drugs 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 an injection provided on December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient physical therapy. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary, and you can receive the care you 
need in another setting. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.