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

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral 
body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar (22514). 
 
You asked the Plan to pre-approve a kyphoplasty procedure. You say that the requested procedure is medically 
necessary due to kyphoplasty because of age-related osteoporosis with current pathological fracture, 
vertebra(e), initial encounter for fracture. The Plan denied your request. The Plan says the details from your 
doctor do not meet Medicare guidelines that show a medical reason you need a kyphoplasty (procedure on your 
back to treat small painful breaks in your back). The request has been denied as the medical necessity 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 a kyphoplasty procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were being treated for age-related osteoporosis with current pathological 
fracture. You presented with lower back pain that is bilateral paralumbar and is constant, dull, ache, and sharp. 
The pain radiates to the right anterior thigh characterized as burning in the L2 distribution. The symptoms 
began 1 month ago. The pain is rated at 7-10/10. The exam reveals intact strength and sensation. Reflexes are 
absent in the bilateral ankles and 1+ in the bilateral patella. However, the MRI from June 1, 2023, 
demonstrated 7mm of retropulsion of the L2 compression fracture. Additionally, there are well documented 
other potential causes of the low back pain. Both of these factors are contraindications for the requested 
procedure. Therefore, you do not meet the coverage criteria detailed in the LCD and the requested kyphoplasty 
at L2 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 a kyphoplasty procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous vertebral augmentation, including cavity creation (fracture 
reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or 
bilateral cannulation, inclusive of all imaging guidance; lumbar (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve 150 additional routine transportation trips. 
 
You asked the Plan to approve these services. You say that you need transportation to upcoming dialysis 
appointments. The Plan denied your request. The Plan says you have exhausted the benefit limit. 
 
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 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used all 60 
one-way trips allowed by your supplemental routine transportation benefit. Based on this information, we 
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to approve 150 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve an advanced electronic foot system. You say that you disagree with the 
denial and have submitted medical documentation for review and reconsideration. The Plan denied your 
request. The Plan says Medicare guidance says that a prosthesis that meets, but does not exceed, the enrollees 
need can be provided. Medicare does not cover replacement for items under warranty. 
 
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 advanced electronic foot system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a diagnosis of diabetes with a right transfemoral 
amputation who requires a lower extremity prosthesis for ambulation. Provided records in this case do not 
document that the enrollees current K3 level ankle-foot system has been lost, stolen, irreparably damaged in a 
specific accident or natural disaster or has reached its reasonable useful lifespan to meet Medicare criteria for 
replacement.  
 
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 advanced electronic foot system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-controlled 
feature, dorsiflexion and/or plantar flexion control, includes power source (L5973).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 21, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says ember has no out-of-network benefits. No medical necessity for an 
out-of-network provider, such as an urgent or emergency situation, has been documented. There is no network 
deficiency for these services and alternate network providers were found. 
 
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 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 physician's services provided on February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 11, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service October 19, 
2022.   
You asked the Plan to pay for procedure code 88374. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 9 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office/outpatient visit (procedure code 99215) rendered on 
January 12, 2023. 
 
You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) code 99215-25 remains 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 99215 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 40-54 minutes of 
total time is spent on the date of the encounter."  
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there was no evidence of a high 
level of decision making. The documentation does not show that 40-54 minutes of total time was spent on these 
services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an office/outpatient visit (procedure code 99215) rendered on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says the facet joint 
injections are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found the enrollee has a chronic low 
back pain, post-laminectomy syndrome and lumbar spondylosis without myelopathy or radiculopathy. The 
enrollee also has a history of chronic neck pain due to cervical spondylosis, without myelopathy or 
radiculopathy. However, there is no documentation stating why the 3-level procedure is necessary. 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the facet joint injections.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve prefabricated abutments and abutment supported crowns (D6056 
and D6058) in areas #3 and #14. 
 
You asked the Plan to pre-approve D6056 and D6058. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says that this dental work is not medically necessary. 
 
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. The Plan covers D6056 and 
D6058 when the services are medically necessary and reasonable. 
 
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 D6056 and D6058. Our reviewer says 
that this dental work is medically necessary. Our physician reviewer found the implant bodies (D6010) have 
been approved for these areas. These restorations will provide adequate masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D6056 and D6058 have been met. Therefore, we decided that the Plan has to 
pre-approve prefabricated abutments and abutment supported crowns (D6056 and D6058) in areas #3 and #14.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provided has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory assist device provided on February 5, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for a respiratory assist device. You say that this is supported in the records. The Plan 
denied your request. The Plan says this 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 a respiratory assist device provided on February 5, 
2023, by an out-of-network (OON) provider.
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. You say that the enrollee is in need of inpatient rehabilitation 
facility admission. The Plan denied your request. The Plan says the enrollee's records do not show that you 
need an intensive team for your care. Services needed may be provided safely in a lower level of care. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Brain imaging, positron emission tomography (PET) 
78608. 
 
You asked the Plan to pre-approve the PET scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the base requirement of the NCD would 
not be satisfied in this case a would therefore not be 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Brain imaging, positron emission tomography (PET) 78608.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation services provided on September 26, 2021. 
 
You asked the Plan to pay for the ambulance transportation services. You say that the enrollee was picked up 
from their home and transported to the emergency department. You say that the claim should be paid. The Plan 
denied your request. The Plan says that the transport happened while the enrollee was inpatient. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that payment for the services were included in the hospital 
payment. However, the Plan has not provided documentation showing payment to a hospital facility related to 
the transportation in question. Additionally, the ambulance transportation was provided from the enrollee's 
residence to the emergency department. As such, payment for the transportation would not be included in the 
facility payment. The Plan has provided no documentation to support that these services would be included in 
the payment to any facility. There is no evidence that the enrollee maintained inpatient status with one facility 
on the date in question or that the enrollee was transported to a different building within the same 
hospital/facility group. These services are not supported as being inpatient transportation. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
ambulance transportation services provided on September 26, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health evaluation provided on January 02, 2023. 
 
You asked the Plan to pay for the mental health evaluation. You say that you received a verbal referral for this 
service. 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 mental health 
evaluation provided on January 02, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of bisphosphonates is required before Prolia can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred 
drugs or any reason they may be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.