Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on January 
26, 2023, by an OON provider.  
 You asked the Plan to pay for the chronic care management services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this service was not 
authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 chronic care management services provided on 
January 26, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine podiatric services provided on April 11, 2023. 
 
You asked the Plan to pay for the routine podiatric services. You say that the services should be covered. The 
Plan denied your request. The Plan says routine foot care is not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine podiatric services have not been met. Therefore, we decided that the Plan does not have to pay for the 
routine podiatric services provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for additional intraoral x-rays, fillings, and mandibular 
partial dentures (D5214, D0220, D2392) provided on December 14, 2021, and intraoral x-ray (D0230) 
provided on December 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 14, 2021 
(D5214, D0220, D2392), December 21, 2021 (D0230 x2), and December 22, 2022 (D0230). Therefore, we 
decided that the Plan does not have to pay more for additional intraoral x-rays, fillings, and mandibular partial 
dentures (D5214, D0220, D2392) provided on December 14, 2021, and intraoral x-ray (D0230) provided on 
December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
August 17, 2022, to August 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that services were not 
properly rendered. 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 $290 
copayment per day, for days 1 to 7 and a $0 copayment per day, for days 8 to 90 of an in-network inpatient 
hospital stay.  
 
 You have been asked to pay a $290 copayment per day, for days 1 to 7 of the inpatient hospital stay. You have 
been asked to pay a total of $2,030 ($290 copayment x 7 days = $2,030). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay provided from August 17, 2022, to August 
25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (22612). 
 
You asked the Plan to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; lumbar. 
You say that this is medically necessary. The Plan denied your request. The Plan says this device is not 
approved for use in a stand-alone procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve arthrodesis, posterior or posterolateral 
technique, single interspace; lumbar. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the Minuteman device is 
experimental. The device does not entail the use of posterolateral fusion surgery. There is no spinal instability 
and fusion is not medically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis, posterior or posterolateral technique, single interspace; lumbar have 
not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, posterior or 
posterolateral technique, single interspace; lumbar (22612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22870, 22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says this device has not been shown to be safe and effective for treatment of the 
enrollee's condition. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22870, 22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level. You say that 
this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary 
because there is little evidence in the medical literature to suggest that this is an appropriate procedure for the 
enrollee's back pain.  
 
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 percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this is an experimental procedure which is 
the subject of ongoing clinical trials. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level (0627T).
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 enrollee would benefit from 
admission to an LTACH to regain a maximum/prior level of functioning and to continue a multidisciplinary 
approach to care. You would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says the enrollee does not all the requirements for admission to an LTACH. 
 
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. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (POV) 
with a patient weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve group 1 heavy duty POV. You say that you need the scooter because you 
cannot get around your house to do anything. The Plan denied your request. The Plan says you do not appear to 
meet criteria because your weight was 266 pounds, which is less than 95% of the lowest weight for POV. The 
Plan also says that per a call with you on July 17, 2023, you did receive a K0800 and are happy with the current 
equipment.  
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. Medicare rules also say that a POV is covered if the beneficiarys weight is less than 
or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the 
weight capacity of the next lower weight class POV. 
 
The file shows that you have a group 1 standard POV with a patient weight capacity up to and including 300 
pounds (K0800). A group 1 standard POV with a patient weight capacity up to and including 300 pounds 
(K0800) serves the same purpose as group 1 heavy duty POV. The provided records also show that your most 
recent documented weight is below the required weight limit of 301 to 450 pounds for a group 1 heavy duty 
POV (K0801). Therefore, we decided that the Plan does not have to pre-approve a group 1 heavy duty power 
operated vehicle (POV) with a patient weight capacity 301 to 450 pounds (K0801).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 billed for date of service November 
21, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was approved by Medicare. The Plan 
denied your request. The Plan says there is a more appropriate code that should be 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, the CPT Code Manual definition of code 81479 is unlisted molecular pathology procedure. We 
find that CPT code 81479 is not supported. The documentation in the appeal shows that the Molecular 
Diagnostics (MolDX) CPT code is provided as a courtesy and should not be relied upon as definitive for 
coverage purposes. There is a more accurate code available that describes the services provided. Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 81479 billed for date of 
service November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 18, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 19, 2022, and 
November 29, 2022. Therefore, we decided that the Plan does not have to pay for periodontal maintenance 
(D4910) provided on August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-ray and CT scan provided on 
October 27, 2022. 
 
You asked the Plan to waive the copayments for the x-ray and CT scan. You say that you thought all 
preprocedural visits were fully covered by the Plan. 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 
copayment for x-rays provided at an outpatient hospital. Your contract with the Plan also clearly says that you must pay a $150 copayment for CT scans provided at an outpatient hospital. 
 
You have been asked to pay a $40 copayment for the x-ray. You have also been asked to pay $134.05, which is 
less than the standard $150 copayment for the CT scan. These items/services fall within the outpatient hospital 
services benefit category. You have been asked to pay a total of $179.05 for these services ($40 copayment + 
$134.05 copayment = $179.05). 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 copayments for the x-ray and CT scan 
provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. You say that the enrollee has had to limit their activities of 
daily living because their symptoms have impacted their quality of life.  The Plan denied your request. The 
Plan says a sacroiliac joint injection 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee's pain is not 
primarily over the anatomic location of the sacroiliac joints, but it is throughout the lower back and in the 
anterior thighs. The pain is clearly noted to be radicular, and the imaging of the lumbar spine show numerous 
potential pain generators including severe adjacent segment disease with subarticular, central canal, and 
foraminal stenosis. Although the enrollee had a positive proactive maneuver such as the FABER, they also had 
a hip compression done which was negative. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing billed for date of service February 10, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the test was medically necessary to determine 
treatment. The Plan denied your request. The Plan says the test did not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The records provided do not indicate the enrollees current cancer 
status or treatment plans. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing billed for date of 
service February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 13, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the OON visit. You say that the treatment was medically necessary. The Plan 
denied your request. The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit provided on December 13, 2022, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care billed for dates of service June 2, 2022, to 
June 25, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the services 
are not separately reimbursed. 
 
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 file shows that the Plan has agreed to pay for all items except for routine items and services. The case file 
does include an itemized bill. However, the Plan has not identified the billed codes they determined are not 
separately payable. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for 
the inpatient hospital care billed for dates of service June 2, 2022, to June 25, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-health related transportation services. 
 
You asked the Plan to pre-approve additional non-health related transportation services. You say that you need 
additional rides because you need assistance to certain locations such as family's houses. The Plan denied your 
request. The Plan says non-health related trips beyond the 24 allotted trips in the 2023 Evidence of Coverage 
are not covered by the Plan.  
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 up to 24 one-way trips for non-health related services per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that this request exhausts the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-health related transportation services.