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

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Sprit PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 Sprit PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/investigational therapy for knee pain. 
 
   
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 Sprit PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 for date of service June 11, 2023. 
 
You asked the Plan to pay for procedure code 83520. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
 
We find that CPT code 83520 is not supported in the medical record. Specifically, code 83520 represents a not 
otherwise specified code. However, a complete description of the note otherwise specified code was not 
included. The order/lab requisition must include what laboratory test was ordered/requested in order to validate 
the not otherwise specified code billed. Based on this information, we decided that Medicare rules for coverage 
of procedure code 83520 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 83520 for date of service June 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on April 25, 2023, to June 5, 2023. 
  
You asked the Plan to pay for the eyeglasses . You say that you bought a pair of eyeglasses on April 25, 2023, 
and are able to receive $250 towards the eyeglasses. You say this is the first claim for 2023 and the benefit 
cannot be exhausted. The Plan denied your request. The Plan says the service is a covered benefit, but you have 
exceeded the benefit limit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $250 for eyeglasses. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $250 towards the eyeglasses provided on 
April 25, 023, which exhausted the benefit. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses provided on April 25, 2023, to June 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 22845-59-AS billed for date of service May 8, 2023. 
 
You asked the Plan to pay for code 22845-59-AS. You say that the additional fixation is not integral to the 
device (cage). The plate and screws are coded and reimbursed separately. The Plan denied your request. The 
Plan says code 22845-59-AS is included in code 22853. The medical records don't support that this service was 
distinct or independent from other services performed. As a result, the 59 modifier is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 22845-59-AS. Our reviewer says that 
the use of the 59 modifier with code 22845 is not supported by the medical record. Our physician reviewer 
found these services are included in the main procedure code of 22853. When billing for such additional code 
that is included, the modifier 59 must be documented that it was not related to 22853. In this case, the documentation does not support that. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 22845-59-AS have not been met. Therefore, we decided that the Plan does 
not have to pay for code 22845-59-AS billed for date of service May 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that as the enrollee continues to require 
hospitalization, they will require extensive rehabilitative therapies to regain strength and a functional quality of 
life. The Plan denied your request. The Plan says based on the information received, the enrollee does not meet 
the guidelines for LTACH services.  
 
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 record indicates the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The elements 
of the coverage rules are not satisfied.   
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45378, 45380). 
 
You asked the Plan to pre-approve a colonoscopy. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 a colonoscopy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided medical records and review of the current peer-reviewed medical literature 
indicate that this enrollee should have a follow-up colonoscopy in three years, not one year. 
 
   
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 colonoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy (45378, 45380).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for outpatient hospital injection services 
provided from June 2, 2023, to June 12, 2023. 
 
You asked the Plan to waive the cost-sharing for outpatient hospital services. You say that the Plan customer 
services told you these services would be covered without cost-sharing. 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 $199 
deductible and $300 copayment for outpatient injection services provided in an outpatient hospital facility. At 
the time the claim for date of service June 2, 2023 was processed, $0 of the $199 deductible had been met. The 
allowed amount of that claim is $228.44, resulting in a deductible amount of $199 which meets the $199 total 
deductible for 2023. For each other date of service, you have been asked to pay the allowed amount of $228.44 
because this is less than the $300 copayment for outpatient hospital injection services. There were 4 such visits, 
resulting in a total copayment amount of $913.76. Therefore, your total cost-sharing responsibility is 
$1,112.76. 
 
You have been asked to pay $199 deductible and less than $300 copayment for outpatient hospital services. 
This item/service falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers 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 cost-sharing 
for outpatient hospital injection services provided from June 2, 2023, to June 12, 2023.  
 
Your complaint about receiving inaccurate information from the Plans customer service is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre sensor. You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the denial of authorization for the requested item is correct, because the enrollee's 
physician ordered a Dexcom. 
 
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. 
 
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 continuous glucose monitor (CGM). 
Our reviewer says that the specific CGM requested is not necessary. Our physician reviewer found that the 
enrollee meets the coverage criteria for a CGM. A Dexcom G6 or G7 would work fine for this enrollee. It is 
unclear why the enrollee wants or needs the Freestyle Libre, and the enrollees Plan seems to prefer a Dexcom. 
If there is additional data as to why the enrollee cannot use a Dexcom, this should be submitted and the case re 
reviewed. 
 
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 continuous glucose monitor (CGM) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Freestyle Libre sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chair portion of a seat lift mechanism (A9270). 
 
You asked the Plan to pre-approve a chair. You say that the item should be covered. The Plan denied your 
request. The Plan says this item does not primarily serve a medical purpose. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the chair portion of a seat lift mechanism (A9270).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator (64555, 64590). 
 
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that this is medically necessary. The 
Plan denied your request. The Plan says this 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 a peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the peripheral nerve stimulator is experimental for chronic back and 
sacroiliac joint pain. 
 
   
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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral nerve stimulator (64555, 64590).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that the enrollee has tolerated samples of Ozempic well 
and is high risk for cardiovascular events and kidney disease. The Plan denied your request. The Plan says that 
self-administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Eligard. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says tier 
exceptions are not available for Part B drugs. 
 
The Plan must follow Medicare rules. Medicare rules state that tiering exceptions cannot apply to Part B drugs. 
Tiering exceptions are only applicable to Part D drugs.  
 
We looked at the file and Medicare rules. The drug you are requesting is considered a Part B drug. As a result, 
no tiering exceptions can be made. Therefore, we decided that the Plan does not have to pre-approve a tier 
exception for Eligard.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on April 18, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that that you were told you could not submit for 
reimbursement until the provider was paid in full. You say you were not informed there was a time frame. The 
Plan denied your request. The Plan says the service was denied as timely filing exceeded. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hearing aids was not filed until May 30, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the hearing aids provided on April 18, 2022.
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 you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested admission is not medically necessary. 
 
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 enrollee was admitted after a fall in which the enrollee sustained a left proximal 
humerus fracture now status post closed reduction, and right fifth metatarsal fracture which was managed 
conservatively. The documentation notes that the enrollee has low activity tolerance due to current pain levels 
which limits any meaningful progression with therapy. The documentation does not support that the complexity 
of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. Therefore, the enrollee does not meet criteria for the requested 
admission. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CX Bladder test (0013M) provided on May 31, 2023. 
 
You asked the Plan to pay for CX Bladder test. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT code 0013M is not a covered service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CX Bladder test have not been met. Therefore, we decided that the Plan does not have to pay for 
the CX Bladder test (0013M) provided on May 31, 2023.
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 you say you disagree with the denial for the 
admission to an IRF. The Plan denied your request. The Plan says the required services can be provided in an 
alternate setting.  
 
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 can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee requires treatment by multiple therapies. There is documentation that there is a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower level 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 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria under CMS guidelines. The Plan 
denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is medically stable for transfer and requires an inpatient level of care that can be 
provided at the chosen LTACH. It is expected that the stay at that level of care would meet or exceed 25 
additional days. Benefits, as noted by the enrollee's physician, include specialized services that can only be 
provided at the chosen LTACH and are beyond the capabilities of alternative levels of care. Documentation of 
the enrollee's condition and care supports this opinion. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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.