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

 
We decided that the Plan does not have to waive the copayment for emergency care provided on August 13, 
2023. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the 
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 emergency care. 
 
You have been asked to pay a $90 copayment for emergency care. This item/service falls within the emergency 
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 emergency care provided on 
August 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker (E0143) with seat attachment (E0156). 
 
You asked the Plan to pre-approve a walker with seat attachment. You say that the requested item is a necessity 
for your care. The Plan denied your request. The Plan says rules for payment for durable medical equipment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a walker (E0143) with seat attachment (E0156).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on June 21, 
2023. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you are appealing the claim 
payment denial. 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 chiropractic 
manipulative treatment provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a backup battery for a CPAP. You say that the requested item is a necessity 
for your care. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature.  
  Therefore, we decided that the Plan does not have to pre-approve a backup battery for a continuous positive 
airway pressure (CPAP) device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on 
September 5, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is not eligible to bill Medicare for mental 
health services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation 
provided on September 5, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 9, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that prior reimbursement has been paid to you for these 
services. The Plan denied your request. The Plan says this provider is not part of the Medicare Program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
August 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator (K1018, K1019). 
 
You asked the Plan to pre-approve the nerve stimulator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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. This item is non-covered. Based on this information, we decided that 
Medicare rules for coverage of the nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nerve stimulator (K1018, K1019).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
February 13, 2023, through February 14, 2023.  
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on January 29, 2023 with 
Schizoaffective Disorder Bipolar Type. Based upon the review of the records provided, it was not expected that 
this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal 
or homicidal ideation, or auditory and visual hallucinations. The enrollee was compliant with treatment while 
not showing any acute threats to safety. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as she did not have dangerousness to self or others and was compliant with her treatment. The 
health plans denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to 
require inpatient mental health treatment beyond the date in question as she was not a danger to herself or 
others and did not have auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services were reasonably expected to improve the 
enrollees condition or were for the purpose of a diagnosis beyond the date in question. It did appear that the 
records were supervised and evaluated by a physician. Based upon the review of the records provided, the 
enrollee does not meet the criteria for coverage of the acute inpatient psychiatric hospital care provided from 
February 13, 2023 forward as she was not shown to be a danger to herself or others, and did not have delusions, 
or auditory and visual hallucinations as noted. She was cooperative/compliant with treatment while not 
showing any threats to safety. 
 
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 pay for the acute inpatient psychiatric hospital care provided from February 13, 2023, through  
February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopic shoulder surgery with placement of a 
subacromial spacer (29999, 29827). 
 
You asked the Plan to pre-approve arthroscopic shoulder surgery with placement of a subacromial spacer. You 
say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 arthroscopic shoulder surgery with 
placement of a subacromial spacer. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested arthroscopic shoulder surgery with placement of a subacromial spacer 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 arthroscopic shoulder surgery with placement of a subacromial spacer have not 
been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopic shoulder surgery with 
placement of a subacromial spacer (29999, 29827).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Omnia Medical CeLLogix Allograft. 
 
You asked the Plan to pre-approve the Omnia Medical CeLLogix Allograft. You say that the Omnia Medical 
CeLLogix Allograft is medically necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the Omnia Medical CeLLogix Allograft in the setting of cervical spine fusion 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 Omnia Medical CeLLogix 
Allograft. Our reviewer says that the requested Omnia Medical CeLLogix Allograft is not considered medically 
reasonable and necessary. Our physician reviewer found that the provided medical records and review of the 
current peer-reviewed medical literature do not document that use of the Omnia Medical CeLLogix Allograft has been shown in controlled studies in a CMS-approved journal to result in sustained long term health benefits 
in patients with cervical spondylosis with radiculopathy undergoing decompression and fusion surgery. 
 
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 Omnia Medical CeLLogix Allograft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Omnia Medical CeLLogix Allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided October 20, 2022, billed with 
codes 87640, 87481, 87798 x 13, 87653, 81003 and 87086. 
 
You asked the Plan to pay for the laboratory testing. You say that please reconsider this claim for payment. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the Urine PCR panel provided October 20, 2022, billed with codes 87640, 87481, 
87798 x 13, 87653, 81003 and 87086.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97750 billed for July 10, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 97750 is not supported. 
 
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 97750 is physical performance test or measurement (eg, 
musculoskeletal, functional capacity), with written report, each 15 minutes. 
 
We find that CPT code 97750 is not supported in the medical record. Specifically, the records contain a 
physical performance test or measurement report but there is no name and signature of the servicing physician 
to validate the records. 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 pay for procedure code 97750 
billed for July 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 6, 2023, billed 
with procedure code 72072-26. 
 
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 two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M54.6 has an Excludes1 note in relation to M51.34. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on February 6, 2023, billed with procedure code 72072-26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that the requested item is a necessity for your care. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for a 
crutch substitute/knee scooter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or the 
Plan.  
  Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement procedure provided on June 7, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the nail debridement procedure. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says the 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 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 nail debridement procedure provided on June 
7, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee had a total hip 
arthroplasty, which puts her at risk for a blood clot. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
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. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on April 29, 2023, to April 
30, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that this service is supported in the records. 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 skilled nursing facility 
provided on April 29, 2023, to April 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that the Vertiflex Superion device is 
medically 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 Vertiflex Superion device. Our 
reviewer says that the requested Vertiflex Superion device is not considered medically reasonable and 
necessary. Our physician reviewer found that the Vertiflex Superion device is experimental. More research is 
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 the Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0652 and a compression pump described by E0667. 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that a PCD coded as E0652 is not covered for the treatment 
of lymphedema of the extremities alone 
 
We looked at the file and Medicare rules. The records show that the enrollee does not have lymphedema 
extending into the chest or trunk. Based on this information, we decided that Medicare rules for coverage of the 
PCD coded E0652 and segmental appliance are not covered. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (PCD) described by code E0652 and a compression pump 
described by E0667.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total electric hospital bed (E0265).  
 
You asked the Plan to pre-approve the hospital bed. You say that the enrollee needs this bed as soon as possible 
and you want to appeal this decision. The Plan denied your request. The Plan says total electric hospital beds 
are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital 
bed (E0265).