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

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of a trial of 
bracing for the enrollee. More conservative measures are needed prior to surgery. The kyphoplasty is therefore 
not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded 81479 for date of service 
December 8, 2022. 
 
You asked the Plan to pay for the laboratory testing coded 81479. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
coded 81479 have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
testing coded 81479 for date of service December 8, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 You asked the Plan to pre-approve Durolane. You say that this medication should be covered. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
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 Durolane. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that you have not tried and failed the Plan's 
required drug, Euflexxa. There is no documentation provided indicating that Euflexxa would likely be less 
effective and/or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee suffers from 
neurogenic claudication due to lumbar spinal stenosis and has failed more than 24 months of conservative 
approaches to treatment. You say that this treatment is supported, and authorization should be approved. The 
Plan denied your request. The Plan says there are not enough studies to show that Vertiflex Superion is safe 
and effective to treat back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is considered experimental, and 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 device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 for dates of service October 21, 2022, to November 9, 2022. 
 
You asked the Plan to pay for the PCD. You say that the enrollee has coverage for durable medical equipment 
based on medical necessity. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PCDs coded as E0675 will be denied as not 
reasonable and necessary. You billed the PCD in question with code E0675, so this is a non-covered item, 
regardless of appropriateness. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device (PCD) billed with code E0675 for dates of service October 21, 2022, to 
November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99283) provided on December 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99283) is included in the global 
surgery payment for the procedure (27880) provided on September 26, 2022, which has a 90-day global period. 
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 the services (99283) provided on December 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 95861 & 95868 billed for date of service 
June 2, 2022.  
 
You asked the Plan to pay for procedure codes 95861 & 95868. You say that these services were medically 
necessary. 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 codes 95861 & 95868 is 1. The MAI value for these codes is 3. You billed 2 
units of each 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 codes 95861 & 95868 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 95861 & 95868 billed for date of service 
June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77300 billed for date of service December 
15, 2022.  
 
You asked the Plan to pay for procedure code 77300. You say that you disagree with the Plan's denial. 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 77300 is 10. The MAI value for this code is 3. You billed 15 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 77300 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 77300 billed for date of service December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit provided on November 30, 2022. 
 
You asked the Plan to reimburse you for the outpatient service. You say that you were advised the provider did 
not accept any insurance. You say that you paid $275 for the office visit. You say that the statement from your 
Plan showed a payment of $138.70 to the provider. You also say that you feel you should get a refund. 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. Your 
contract with the Plan says that there is a $1,200 deductible which applies to covered medical services.  
 
The item or service you asked the Plan to reimburse you for is covered medical service to which the annual 
deductible applies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1,200 deductible which applies to covered medical services. This cost sharing is a contractual obligation that 
had not been met at the time the outpatient service was received on November 30, 2022. Therefore, we decided 
that the Plan does not have to reimburse you for the office visit provided on November 30, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve stab phlebectomy of varicose veins (37765). 
 
You asked the Plan to pre-approve stab phlebectomy of varicose veins. You say that the enrollee has tried 
compression stockings for years without symptom improvement and the vein measured 4.5 mm with significant 
reflux. The enrollee has been developing recurrent bouts of thrombophlebitis involving a large cluster of 
varicose veins in her thigh. She also has limited her daily activities that require her to be on her feet such as 
walking, baking and gardening due to her pain she is experiencing. The Plan denied your request. The Plan 
says that this is not medically necessary. 
 
The Plan follows Medicare 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 stab phlebectomy of varicose veins. 
Our reviewer says that coverage criteria are met for the requested service. Our physician reviewer found for 
stab phlebectomy to be considered medically necessary, there needs to be documentation that the veins in 
question are greater than 4 mm in diameter (condition met) and there needs to be documentation that the 
saphenous reflux is absent or previously treated. In this case the enrollee has undergone previous vein stripping 
(therefore criterion met). While there are areas of saphenous reflux it is carefully documented by the provider 
that these areas of reflux are remote from the area of treatment and therefore do not constitute the presence of 
saphenous reflux with respect to 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 stab phlebectomy of varicose veins have been met. Therefore, we decided that 
the Plan has to pre-approve stab phlebectomy of varicose veins (37765).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on January 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. No 
clinical records were provided to support that this service was medically necessary. Only lab results were 
provided for review. Therefore, we decided that the Plan does not have to pay for lab services (G0482) 
provided on January 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 27, 2022, to 
October 31, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe you timely filed this NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 28, 2022. The NOA was not received by the Plan until January 5, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Please note that although you contend you filed a NOA on July 29, 2022, that information 
doesn't match up with the claim in dispute.  For this claim, you submitted an admit date of August 28, 2022, 
which is a month after you claim you submitted the NOA.  This is not possible.  If your intent was to submit a 
corrected document, please contact the Plan about that directly. Therefore, we decided that the Plan does not 
have to pay for home health services provided from October 27, 2022, to October 31, 2022.
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 admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. Skilled therapies at home or at a skilled nursing facility (SNF) may be approved upon 
request. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service February 20, 
2023.  
 
You asked the Plan to pay for procedure code 88377. You say that you disagree with the Plan's denial. 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 88377 is 5 The MAI value for this code is 3. Five (5) units of this code was 
billed under another claim which was previously processed and paid by the Plan. You billed 1 additional unit of 
this code, equaling 6 total units, 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 88377 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88377 billed for date of service 
February 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's continued care needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled therapy 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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for and waive the cost-sharing for ophthalmology office visits, 
cataract surgeries, self-administered drugs, and presbyopia-correcting lens upgrades provided from February 
16, 2022, to March 31, 2022. 
 
You asked the Plan to pay for and waive the cost-sharing for specialist visits, cataract surgeries, drugs, and 
presbyopia-correcting lens upgrades. You say that  The Plan denied your request. The Plan says this cost 
sharing was charged correctly. The Plan also says that the self-administered drugs and presbyopia-correcting 
intraocular lens (IOL) upgrades are not covered by Medicare. 
 
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 $40 
copayment for each specialist visit and $250 copayment for each outpatient surgery. You had 2 specialist visits 
and 2 visits for cataract surgery, resulting in a total cost-sharing amount of $580. The rules say that Medicare 
does not typically pay for self-administered drugs. The rules also say that if an enrollee receives a presbyopia 
correcting intraocular lens during cataract surgery, the enrollee will be responsible for the different in cost 
between the presbyopia correcting intraocular lens and a conventional intraocular lens. 
 
You have been asked to pay $40 copayment for each specialist visit and $250 copayment for each outpatient 
surgery. These services fall within the "Vision Care" and "Outpatient Surgery, Including Services Provided at 
Hospital Facilities and Ambulatory Surgical Centers" benefit categories. 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 pay for 
and waive the cost-sharing for ophthalmology office visits, cataract surgeries, self-administered drugs, and 
presbyopia-correcting lens upgrades provided from February 16, 2022, to March 31, 2022.