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

 
We decided that the Plan does not have to pre-approve a T10, T11 kyphoplasty (22513).  
You asked the Plan to pre-approve the kyphoplasties. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the documentation does not indicate 25% vertebral body height 
reduction. The Plan also says the imaging indicates additional pathology. 
 
The Plan follows Medicare rules. Medicare rules say that and percutaneous vertebral augmentation (PVA or 
Kyphoplasty) procedures will be considered medically reasonable and necessary for painful, debilitating, 
osteoporotic vertebral collapse/compression fractures, defined as those that have not responded to non-surgical 
medical management (e.g. narcotic and/or non- narcotic medication, physical therapy modalities) with and 
without methods of immobility (e.g. rest, bracing). 
 
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 kyphoplasties. Our reviewer says 
that the requested kyphoplasties are not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee has trialed non-surgical management, including bracing. 
Therefore, the reviewer found that the requested kyphoplasties are 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 kyphoplasties have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a T10, T11 kyphoplasty (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure. 
 
You asked the Plan to pre-approve the VivAer procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of the VivAer 
procedure in the setting of nasal turbinate hypertrophy have not been demonstrated in the peer-reviewed 
literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation does not support that the VivAer procedure is medically 
reasonable and necessary for the enrollee in this case. Additionally, the requested procedure is not the standard 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 the VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided April 26, 2022, billed with 
evaluation and management (EM) code 99221. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was inappropriately billed with 
POS 21 as the enrollee was registered outpatient observation on this date of service. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided April 26, 2022, billed with evaluation and 
management (EM) code 99221.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on October 27, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 06, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. 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 the office visit provided 
on March 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on 
March 21, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) provided on March 21, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service April 10, 
2023.  
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service April 10, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for  the lipid panel testing (80061) provided July 27, 2022. 
 
You asked the Plan to pay for  the laboratory service. You say that you were told you are allowed one lipid test 
per year and since your previous test was two and a half years ago, this should have been paid. The Plan denied 
your request. The Plan says that the Plan has paid the maximum amount covered for this service. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided any documentation that shows the laboratory service 
was previously paid. The Plan has not provided any documentation to substantiate their reason to continue to 
deny payment. The records show that the service was rendered by a contract provider. The file does not show 
that the Plan provided notice that the laboratory service would not be covered. Under Medicare rules, this 
means the laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to 
pay for  the lipid panel testing (80061) provided July 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology services (81479) provided 
on October 17, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the pathology services. You say that you disagree with the determination and 
formally appeal and request a redetermination of the plan's denial. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 the unlisted molecular pathology services (81479) 
provided on October 17, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4223 billed for date of service March 16, 
2023, to March 17, 2023. 
 
You asked the Plan to pay for procedure code A4223. The Plan denied your request. The Plan says procedure 
code A4223 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A4223 has a status indicator of X on the Physician Fee Schedule. This means that 
procedure code A4223 is not payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code A4223 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A4223 billed for date of service March 16, 2023, to March 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital stay following a shoulder surgery 
(23472). 
 
You asked the Plan to pre-approve an inpatient hospital stay. The Plan denied your request. The Plan says the 
enrollee does not meet any of the requirements for an inpatient hospital stay. 
 
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 pre-approve an inpatient hospital stay. Our reviewer 
says that the documentation does not support that the criteria for an inpatient hospital stay are met in this case. 
Our physician reviewer found the provided documentation did not describe the enrollee's medical history as 
including a high risk or unstable condition that would expect the enrollee to require hospital services that would 
likely cross 2 midnights for this typically ambulatory procedure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient hospital stay have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient hospital stay following a shoulder surgery (23472).
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 you do not meet the 
criteria for admission to an IRF. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer found that 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 you 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network hospital observation 
provided from February 14, 2023, to February 16, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network hospital observation. You say that you do 
not understand what this secondary charge is. You were hospitalized. 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 40% 
coinsurance for outpatient hospital observation.  
 
You were in an out-of-network observation for two days, resulting in the $1,063.39 (40%) coinsurance. You have been asked to pay a $1,063.39 coinsurance for an out-of-network hospital observation. This 
item/service falls within the outpatient hospital observation 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 out-of-network hospital observation provided from February 14, 2023, to 
February 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 level foot and knee. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a K3 prosthesis are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that the 
enrollee is able or expected to ambulate at a K3 functional level. There is no clear documentation to support 
that he requires upgraded components, including the K3 level foot and knee. The criteria for coverage are not 
met and the services are not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a K3 level foot and knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom 7 continuous glucose monitor (CGM) 
(E2103) and supply allowance for nonadjunctive, nonimplanted CGM (A4239). 
 
You asked the Plan to pre-approve a Dexcom 7 CGM and supply allowance. You say that this is medically 
necessary for the enrollee due to low blood sugar at night. The Plan denied your request. The Plan says this 
request is not medically necessary because the records do not show that the enrollee's current CGM is over five 
years old, or that it has been lost or suffered irreparable damage due to an accident or a natural disaster. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. The rules 
also say that Medicare considers equipment to be reasonable and necessary if the equipment does not serve the 
same purpose as other equipment already available to an 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 a Dexcom 7 CGM and supply 
allowance. Our reviewer says that this request is not medically necessary. Our physician reviewer found 
although the enrollee meets criteria for CGM use, it is unclear why the Dexcom G6 is not sufficient for their 
needs at this time. Our reviewer also found that it does not seem as if the Dexcom G6 is malfunctioning or has 
been damaged in any way. 
 
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 Dexcom 7 CGM and supply allowance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom 7 continuous glucose monitor (CGM) (E2103) 
and supply allowance for nonadjunctive, nonimplanted CGM (A4239).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64455 billed for date of service December 5, 
2022.  
 You asked the Plan to pay for procedure code 64455. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64455 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64455 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64455 billed for date of service December 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 3, 2023, to April 
1, 2023. 
 You asked the Plan to pay for the home health services. You say that you have supplied medical records to 
show the medical necessity of these services. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 1, 2023. The NOA was not received by the Plan until April 19, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 3, 2023, to April 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis provided on February 7, 2023. 
 
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the item provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the orthosis provided on February 7, 2023.