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

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is 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 an ILR. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any 
other apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in this patients 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 01, 2021. 
 
You asked the Plan to pay for office visit. You say that you are requesting the submitted documentation be 
reviewed. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
November 01, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on June 10, 
2022. 
 
You asked the Plan to pay for the CGM. You say that the CGM was prescribed to the enrollee by their primary 
health provider to manage their condition. You also say that this is a covered benefit. The Plan denied your 
request. The Plan says the CGM is not a covered benefit unless all of the criteria have been met.  
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 require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person 
visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided 
on June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Sprint PNS neurostimulator (64555). 
 
You asked the Plan to pre-approve placement of the Sprint PNS neurostimulator. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 placement of the Sprint PNS 
neurostimulator. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this service is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of placement of the Sprint PNS neurostimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve placement of the Sprint PNS neurostimulator (64555).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
January 03, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not think you 
should be responsible for this copayment. 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 $90 
copayment for each emergency care visit. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
each emergency care visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit provided on January 03, 2023.
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 the LTACH can render services that will 
improve the enrollee's condition an avoid unnecessary hospital readmission. The Plan denied your request. The 
Plan says the requested LTACH admission is not medically necessary. 
 
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. The enrollee 
appears to be improving with current treatment and should only require short-term additional acute care 
services that can safely be administered at the current facility until the enrollee is more stable and appropriate 
for a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable enough for transfer and as it would not be clinically advantageous.   
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoscopic sleeve gastrectomy. 
 
You asked the Plan to pre-approve an endoscopic sleeve gastrectomy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is 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 an endoscopic sleeve gastrectomy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested treatment endoscopic sleeve gastrectomy is not a covered primary 
treatment for obesity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an endoscopic sleeve gastrectomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an endoscopic sleeve gastrectomy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on December 15, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you dont understand why the Plan 
did not pay for this charge. 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 $170 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $170 copayment for the ultrasound. This item/service falls within the in-network 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. However, since the allowed amount is less than the 
standard copayment, you only owe $112.47. Therefore, we decided that the Plan does not have to waive the 
copayment for the ultrasound provided on December 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 12, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the inpatient facility 
payment. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record shows that the enrollee was 
admitted as inpatient to the origin location provider. The record did not include adequate documentation 
showing that the enrollee was discharged from the original provider when transported to another provider. This 
means that the ambulance service appears to be covered as an inpatient hospital service and is not separately 
billable. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on 
December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment provided on August 
31, 2022. 
 
You asked the Plan to pay for remote physiologic monitoring treatment. You say that you are requesting 
reconsideration for the services provided. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote physiologic 
monitoring treatment provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator (K1018). 
 
You asked the Plan to pre-approve a nerve stimulator. You say that this is medically necessary. The Plan 
denied your request. The Plan says where electric nerve stimulation is employed to treat motor function 
disorders, no reimbursement may be made for the stimulator or for the services related to its implantation since 
this treatment cannot be considered reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a nerve stimulator (K1018).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the progressive lenses (V2781) purchased on February 
14, 2022, from an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the progressive lenses. You say that you would like the lenses purchased on 
February 14, 2022, to be covered under the 2021 benefit year. You also say that the reason is because the 
prescription was written in 2021 but you were not able to get it filled until February 14, 2022, due to 
circumstances beyond your control. The Plan denied your request. The Plan says this claim denied correctly 
because a pair of glasses was already paid in February 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $90 per calendar year for standard eyeglasses purchased from a 
nonparticipating provider.  
We looked at the file and the Plan's rules. The record shows that you received these lenses from an OON 
provider, and the $90 allowance was correctly applied to your claim per your 2022 Evidence of Coverage. 
Unfortunately, your benefits from the 2021 plan year cannot be used because this purchase was made in 2022. 
Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have not been 
met. Therefore, we decided that the Plan does not have to pay more for the progressive lenses (V2781) 
purchased on February 14, 2022, from an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652 and E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the member does not have lymphedema in the arms or 
legs. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema of an extremity. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (E0652 and E0657).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. 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, for 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 September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical boot/shoe (L3260). 
 
You asked the Plan to pre-approve a surgical boot/shoe. You say that you need this item. The Plan denied your 
request. The Plan says this is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that orthopedic shoes can be covered in limited 
circumstances.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a surgical boot/shoe have not been met. Therefore, we decided that the Plan does not have to pre-
approve a surgical boot/shoe (L3260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care support supplies provided on January 17, 2023. 
 
You asked the Plan to pay for wound care support supplies. You say that wound care supplies are a separately 
billable expense that does not require an authorization or a referral. The Plan denied your request. The Plan 
says that unauthorized, out-of-network care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care support 
supplies provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry (83789) provided on October 24, 2022. 
 
You asked the Plan to pay for mass spectrometry. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says validity testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry have not been met. Specifically, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for mass spectrometry (83789) provided on October 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiflex device placement surgery (22869). 
 
You asked the Plan to pre-approve a vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a vertiflex device placement surgery. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental. 
 
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 vertiflex device placement surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a vertiflex device placement surgery (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you are appealing the denial for procedure 
codes 99233, 45378 and 43235 The Plan denied your request. The Plan says payment for code 99233 is 
bundled into payment for code 45378. 
 
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 99233 
is a column II code to column I code 45378. 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 99233 billed for date of service July 1, 2022.