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

 
We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation (RFA) 
(64635, 64636).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
   
 
 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet all of the indicated criteria. 
 
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 this service. Our reviewer says that the 
enrollee does not meet the criteria for coverage of the requested service. Our physician reviewer found that the 
enrollee has a history of chronic axial low back pain due to lumbar spondylosis without myelopathy or 
radiculopathy. She had a successful lumbar medial branch block in February, 2022. She reported an estimated 
80% pain reduction after a period of time that lasted for approximately 8 months. She has since had returning 
severe axial low back pain. A repeat lumbar medial branch block (MBB) was performed to ensure that the 
radiofrequency ablation (RFA) would help reduce her pain. She reported 50-60% relief in pain and noted a 
considerable increase in her ability to function, walk, and perform her activities of daily living. Lumbar facet 
joint RFA has been recommended. In this case, the second medial branch block provided only 50-60% relief of 
pain. The review has determined that the enrollee does not meet the criteria indicated in the LCD for coverage 
of the requested service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar facet joint radiofrequency ablation (RFA) (64635, 64636).
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 a lower level of care is not safe, sufficient or 
equipped to address the enrollee's needs related to their comorbidities and allow them the opportunity to gain a 
higher level of functioning to improve their quality of life. The Plan denied your request. The Plan says the 
inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical 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 this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles, a seat pouch. an impact guard, neoprene 
and adductor cover with gel insert (K0108x6). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested accessories do 
not serve a primary medical need. 
 
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 push handles, a seat pouch. an impact guard, neoprene and 
adductor cover with gel insert (K0108x6).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with multiple power 
options (tilt/recline, legrest) and accessories. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says there is no medical need 
for the requested multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 power wheelchair with multiple power 
options may be covered when certain 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 a Group 2 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 2 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided documentation indicates the 
enrollee has a mobility limitation that impairs mobility related activities of daily living (MRADLs) 
participation and is unable to be alleviated by a cane, walker, or manual wheelchair due to weakness and being 
non ambulatory. The reviewer found that the documentation does not specifically state that the enrollee is at 
high risk for development of a pressure ulcer. The enrollee does not utilize intermittent catheterization for 
bladder management. The reviewer found that power seating is not needed to manage increased tone or 
spasticity. Therefore, the reviewer found that the requested Group 2 power wheelchair with multiple power 
options is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 2 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with multiple 
power options (tilt/recline, legrest) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on May 1, 2023. 
 You asked the Plan to pay for infrared therapy. You say that infrared therapy was medically necessary. The 
Plan denied your request. The Plan says infrared therapy is considered not reasonable and necessary by 
Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the use of infrared therapy devices and any related 
accessories is not reasonable and necessary. The rules say that items and services that are not medically 
necessary are not covered. 
 
The services at issue in this appeal are for infrared therapy. Therefore, we decided that the Plan does not have 
to pay for infrared therapy provided on May 1, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36226 and 36227 rendered on April 26, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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 the services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
documentation supports that the services in question were rendered. While CPT code 61645 is bundled with all 
catheterizations and imaging in the territory of the treated clot, selective access of additional vessels outside the 
territory of the clot is separately reportable.  In this case, the internal carotid artery and its branches were in the 
territory of the clot. However, the provider also selected and imaged the external carotid artery and vertebral 
artery as coded with 36227 and 36226 respectively. There is satisfactory documentation of catheterization and 
imaging details to justify billing and coverage of both codes in question.  
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 36226 and 36227 rendered on April 26, 2023.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
April 25, 2023, to April 29, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford the 
copayment. 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 $380 
copayment for inpatient hospital care. 
 
You have been asked to pay a $380 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital 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. You have been asked to pay a total of $1,520 for the inpatient hospital stay ($380 
copayment x 4 days = $1,520). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on April 25, 
2023, to April 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 13, 2023, by an out-
of-network (OON) provider.  
 
  You asked the Plan to pay for practitioner services. You say that the services took place in the nursing home 
where the enrollee currently resides, and your company is the only one contracted with the nursing home to 
provide services for their patients. The Plan denied your request. The Plan says the original decision to deny 
payment was correct. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on June 13, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on July 18, 2023, to July 21, 
2023. 
 
You asked the Plan to pay for the outpatient services. 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 outpatient services 
provided on July 18, 2023, to July 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network vibrating back brace 
provided on May 02, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network vibrating back brace. You say that you want 
to appeal this cost amount, it is too high. 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 50% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 50% coinsurance for an out-of-network vibrating back brace. This item/service 
falls within the prosthetic devices and related supplies 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. The total you owe is $483.56 ($967.11 x 50% = $483.56). 
Therefore, we decided that the Plan does not have to waive the coinsurance for an out-of-network vibrating 
back brace provided on May 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard Esophageal DNA test (0114U) provided June 
8, 2023. 
 You asked the Plan to pay for the genetic testing. You say that you are appealing for EsoGuard that was denied 
for non-covered routine or screening exam. The Plan denied your request. The Plan says per the DEX 
Diagnostics Exchange Registry, EsoGuard is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Per the DEX Diagnostics Exchange Registry, EsoGuard is not 
covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the EsoGuard Esophageal DNA test 
(0114U) provided June 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided on July 18, 2023. 
 
You asked the Plan to waive the copayment for an EKG. You say that you asking the plan to adjust the bill. 
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 $95 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $95 copayment for an EKG. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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. However, since the allowed amount is less than the standard copayment, you only owe $58.79. Therefore, we decided that the Plan does not have to waive the copayment 
for an EKG provided on July 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard testing (0114U) provided June 23, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that you are appealing for EsoGuard that was 
denied as non-covered routine or screening exam. The Plan denied your request. The Plan says per the DEX 
Diagnostics Exchange Registry, EsoGuard is considered non-covered after the MolDx program evaluation.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the EsoGuard testing (0114U) provided June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power standing function (E2301). 
 
You asked the Plan to pre-approve a power standing function. You say that you would like to appeal a power 
standing system for the enrollees electric wheelchair. The Plan denied your request. The Plan says this item is 
not a covered benefit because it is not primarily medical in nature. 
 
 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that a power standing feature (E2301) is non-covered because it is not 
primarily medical in nature.  
 
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 a power standing function (E2301).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the removal of recurring cataract provided 
on July 26, 2022. 
 
You asked the Plan to waive the copayment for the removal of recurring cataract. You say that you were told 
that you would not have a copayment. 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 $250 
copayment for outpatient procedures/surgery at an ambulatory surgical center. 
 
You have been asked to pay a $250 copayment for the removal of recurring cataract. This item/service falls 
within the outpatient procedures/surgery at an ambulatory surgical center 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. However, since the allowed amount is 
less than the standard copayment, you only owe $246.53. Therefore, we decided that the Plan does not have to 
waive the copayment for the removal of recurring cataract provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2019 billed for date of service June 14, 
2023. 
 
You asked the Plan to pay for procedure code H2019. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2019 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code H2019 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2019 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2019 billed for date of service June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the defibrillator vest provided on May 01, 
2023. 
 
You asked the Plan to waive the coinsurance for the defibrillator vest. You say that you cannot afford the 
copayment. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the defibrillator vest. This item/service falls within the 
durable medical equipment and related supplies 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. The total amount you owe is $669.80 ($3,348.99 x 20% = 
$669.80). Therefore, we decided that the Plan does not have to waive the coinsurance for the defibrillator vest 
provided on May 01, 2023.