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

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow 
aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the surgery. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of bone marrow aspiration in conjunction with the planned cervical spine 
surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone 
marrow aspirate for this enrollees medical condition as discussed above. Therefore, the requested bone 
marrow aspirate 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 the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on March 06, 2023. 
 
You asked the Plan to pay for a new patient office visit. You say that this is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a new patient office visit 
provided on March 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on July 25, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were 
unaware there would be a copayment and the doctor did not mention a copayment on date of service. 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 $300 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $300 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
computed tomography (CT) scan provided on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and related services provided on 
October 12, 2022. 
 
You asked the Plan to pay for a new patient office visit, and related services. You say that you do not think you 
need a referral. 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 a new patient office 
visit, and related services provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on May 31, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and should be covered. 
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 a facility visit provided 
on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on December 8, 
2022 
 
You asked the Plan to pay for the GeneSight Psychotropic test. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services rendered are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight Psychotropic testing is not covered. 
 
We looked at the file and Medicare rules. The GeneSight Psychotropic test at issue is specifically not covered. 
Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic test 
have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic 
test provided on December 8, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and chronic care 
management services provided on June 22, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and chronic care management services. You say 
that these services were medically necessary. 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 subsequent nursing 
facility care, and chronic care management services provided on June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adapter plate (K0108) for a Group 3 power 
wheelchair. 
 
You asked the Plan to pre-approve adapter plate. You say that the enrollee is in full need of this equipment. 
The Plan denied your request. The Plan says this component is included in the already approved power 
tilt/recline feature. 
 
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 adapter plate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the seating system is all-inclusive per Medicare rules. Therefore, this requested component is 
unbundled. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of adapter plate have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an adapter plate (K0108) for a Group 3 power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block (64450), triamcinuolene 
injection (J3301), and gadobutrol injection (A9585). 
 
You asked the Plan to pre-approve the genicular nerve block, triamcinuolene injection, and gadobutrol 
injection . You say that the service is medically necessary. The Plan denied your request. The Plan says the 
service is considered experimental. 
 
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 genicular nerve block, 
triamcinuolene injection, and gadobutrol injection. Our reviewer says that the requested services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found this service is 
considered experimental. 
 
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 genicular nerve block, triamcinuolene injection, and gadobutrol injection 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the genicular nerve block 
(64450), triamcinuolene injection (J3301), and gadobutrol injection (A9585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
11, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this should be a 
preventative service. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on October 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 26, 2023, to May 27, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you thought 
because you were admitted, the copayment would be waived. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room (ER) visit provided on May 26, 2023, to May 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vertical shock reducing pylon (L5988) for the
enrollee.

You asked the Plan to pre-approve a vertical shock reducing pylon. You say that the vertical shock pylon
feature is medically necessary to reduce impact and stress to the enrollee's healing residuum. The Plan denied
your request. The Plan says that the requested vertical shock reducing pylon (L5988) exceeds the enrollee's
needs and cannot be covered.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a vertical shock
reducing pylon. Our Medical Director states that the enrollee has a medical history that includes peripheral
arterial disease, chronic obstructive pulmonary disease (COPD), diabetes and hypertension. The enrollee
underwent a right below-knee amputation on January 13, 2023. The available clinical documentation is
insufficient to support that the vertical shock reducing pylon was medically reasonable and necessary for the
enrollee in this case. Our Medical Director found that the enrollee's condition does not meet criteria for
coverage of a vertical shock reducing pylon.

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 vertical shock reducing pylon have not been met. Therefore, we decided that
the Plan does not have to pre-approve a vertical shock reducing pylon (L5988) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft, morselized, or placement of osteopromotive 
material, for spine surgery only--iFactor Cerapedics identified with code 20930. 
 
You asked the Plan to pre-approve allograft, morselized, or placement of osteopromotive material. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services 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 allograft, morselized, or placement of 
osteopromotive material. 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 failed conservative 
management. Imaging reveals severe disc degeneration at L4-L5, L5--S1. IFactor osteopromotic allograft is 
experimental. Iliac crest bone graft is the gold standard. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft, morselized, or placement of osteopromotive material have not been 
met. Therefore, we decided that the Plan does not have to pre-approve allograft, morselized, or placement of 
osteopromotive material, for spine surgery only--iFactor Cerapedics identified with code 20930.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve a PVA. You say that this outpatient surgery is medically necessary for this 
enrollee. The Plan denied your request. The Plan says the medical criteria for a PVA 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 PVA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented trial and failure of fracture bracing. 
 
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 PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a percutaneous vertebral augmentation (PVA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx urinary tract infection (UTI) panel provided on 
October 18, 2022, and billed with codes 87481 and 87798. 
 
You asked the Plan to pay for the Altru Dx UTI panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Altru Dx UTI panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the Altru Dx urinary tract infection (UTI) panel 
provided on October 18, 2022, and billed with codes 87481 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management services and the remote physiologic 
monitoring provided on April 30, 2023. 
 
You asked the Plan to pay for the care management services and the remote physiologic monitoring. You say 
that the assisted living facility is responsible to obtain prior authorization for all of their patients. 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 care management 
services and the remote physiologic monitoring provided on April 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors, a harness and an expandable controller. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the enrollee is able to operate the independent power 
option controls of the requested power seating options. 
 
The Plan follows Medicare rules. Medicare rules say that these power wheelchair features are covered when the 
criteria in the rules section of this letter 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 an electronic connection between 
wheelchair controller and two or more power seating system motors, a harness and an expandable controller.. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that the enrollee 
has sufficient strength and function in upper extremities to manage standard power drives. 
 
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 electronic connection between wheelchair controller and two or more power 
seating system motors, a harness and an expandable controller. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 06, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 office visit provided 
on July 06, 2023.