Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brand specific home eye monitoring device (0379T). 
 
You asked the Plan to pre-approve a brand specific home eye monitoring device (0379T). You say that this 
diagnostic test is federal drug administrative (FDA) approved and has been covered by Medicare since 2015. 
The Plan denied your request. The Plan says they have determined that this service is not covered under 
Medicare. 
 
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 brand specific home eye monitoring 
device (0379T). Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the treating provider has recommended the available 
medical appropriate alternative of eye home testing. Our physician reviewer also found that there is no 
documentation that the enrollee is unable to perform the appropriate alternative. 
 
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 brand specific home eye monitoring device (0379T) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a brand specific home eye monitoring device 
(0379T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are deconditioned and have suffered from renal 
failure, heart failure and urosepsis failure. You say that you will benefit from inpatient rehabilitation to get 
back to your baseline of function.  The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and your needs can be met at an alternate 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft (20931), arthrodesis (22551, 22552), 
anterior instrumentation (22846), and total disc arthroplasty (22856, 22858). 
 
You asked the Plan to pre-approve an allograft, arthrodesis, anterior instrumentation, and total disc 
arthroplasty. You say that this is medically necessary. The Plan denied your request. The Plan says this type of 
surgery has not yet been shown to be better or safer than standard surgeries. 
 
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 allograft, arthrodesis, anterior 
instrumentation, and total disc arthroplasty. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found cervical total disc 
replacement combined with multilevel fusion is not Food and Drug Administration (FDA) approved and is still 
experimental 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 an allograft, arthrodesis, anterior instrumentation, and total disc arthroplasty 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an allograft (20931), 
arthrodesis (22551, 22552), anterior instrumentation (22846), and total disc arthroplasty (22856, 22858).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had a negative non-invasive workup. The enrollee has no cardiac 
symptoms. Documentation does not reveal the rationale for this invasive imaging study. Guidelines do not 
support a need for cardiac catheterization in this setting. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Minuteman G3R interspinous device 
to L2-L3 (22612). 
 
You asked the Plan to pre-approve implantation of the Minuteman G3R interspinous device to L2-L3. You say 
that this is medically necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the Minuteman interspinous device in the setting of back pain, 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 implantation of the Minuteman G3R 
interspinous device to L2-L3. 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. 
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 implantation of the Minuteman G3R interspinous device to L2-L3 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve implantation of the Minuteman 
G3R interspinous device to L2-L3 (22612).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance services (A0428). 
 
You asked the Plan to pre-approve non-emergency ambulance services. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the records do not 
document the enrollee is truly bed-bound nor is there documented acute conditions which require continuous 
monitoring. The review has determined that the documentation does not support that other means of transport 
(such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this 
enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and 
life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve non-emergency ambulance services (A0428).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00811 provided on February 26, 2023. 
 
You asked the Plan to pay for procedure code 00811. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that for purposes of payment under the Medicare Physician 
Fee Schedule (MPFS), the place of service (POS) code is generally used to reflect the actual setting where the 
beneficiary receives the face-to-face service. However, there are two exceptions to this general rule  these are 
for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 00811 have not been met. The file shows that the enrollee was registered as an 
inpatient of a hospital on the date of service procedure code 00811 was provided. The outpatient POS code on 
the claim is inappropriate in this case. Therefore, we decided that the Plan does not have to pay for procedure 
code 00811 provided on February 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not 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. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on December 02, 2022, to 
January 23, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that you were previously in-network and would 
like an exception for these claims. 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 podiatry services 
provided on December 02, 2022, to January 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on October 28, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you are requesting reconsideration of 
the denied services. 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 psychotherapy 
services provided on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthrotomy (27310) and reconstruction of dislocated 
patella (27422) provided on May 21. 2022. 
 
You asked the Plan to pay for the knee arthrotomy (27310) and reconstruction of dislocated patella (27422). 
You say that modifier 59 is on the charges to explain that they are separately allowable, and the claim should 
be reviewed. The Plan denied your request. The Plan says procedure codes 27310 and 27422 are considered 
inclusive to procedure code 27487. 
 
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, we have confirmed that code 27310 and 27422 are column II codes to column I code 27487; 
however, 27310 and 27422 were billed with a modifier.  
 
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 knee arthrotomy (27310) and reconstruction of dislocated 
patella (27422). Our reviewer says that modifier 59 is not supported. Our reviewer found the procedures were 
performed in the same anatomical location as the more comprehensive procedure. 
 
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 knee arthrotomy (27310) and reconstruction of dislocated patella (27422) 
have not been met. Therefore, we decided that the Plan does not have to pay for the knee arthrotomy (27310) 
and reconstruction of dislocated patella (27422) provided on May 21. 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Trias foot and c-leg knee. 
 
You asked the Plan to pre-approve the Trias foot and c-leg knee . You say that the items are medically 
necessary. The Plan denied your request. The Plan says that the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 Trias foot and c-leg knee. Our 
reviewer says that the requested items are considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records indicate the enrollee has K3 functional level potential and has 
specific needs for the requested components. 
 
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 Trias foot and c-leg knee have been met. Therefore, we decided that the 
Plan has to pre-approve the Trias foot and c-leg knee.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cross facial nerve graft. 
 
You asked the Plan to pre-approve a cross facial nerve graft. You say that you would like to be able to smile 
again. The Plan denied your request. The Plan says this surgery is cosmetic in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 cross facial nerve graft. Our reviewer 
says that this procedure is cosmetic in nature. Our reviewer found the record provided is insufficient to 
establish that the requested service is to repair a functional impairment or that other standard therapies have 
failed. The record provided documents that the requested procedure is for facial symmetry and is therefore 
considered cosmetic in nature.  
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 cross facial nerve graft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cross facial nerve graft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug injection provided on August 31, 2022. 
 
You asked the Plan to pay for the drug injection. You say that you are requesting reconsideration for the denied 
payment. 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 drug injection 
provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the drugs, the therapy procedures, and the 
home management training provided by an in-network provider from January 1, 2023, to January 10, 2023.   
 
You asked the Plan to waive the cost sharing for the drugs, the therapy procedures, and the home management 
training. You say that you think that these services should be covered. 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 20% 
coinsurance for all other in-network Medicare-covered Part B drugs that are not Medicare-covered Part B 
allergy antigens, and a $30 copayment for each in-network Medicare-covered physical therapy and speech-
language therapy visit. 
 
You have been asked to pay a $13.71 coinsurance for the drugs because the allowed amount for each service is 
less than the 20% coinsurance. These items/services fall within the Medicare Part B prescription drugs benefit 
category. You have also been asked to pay a $120 copayment for the therapy procedures, and the home 
management training ($30 x 4 services = $120). 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 
the drugs, the therapy procedures, and the home management training provided by an in-network provider from 
January 1, 2023, to January 10, 2023.