Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
the requested items 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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee has adequate upper-body strength 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 expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311).
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 76800. We decided that the Plan does not have to pay 
for procedure code 22552.  
 
You asked the Plan to pay for procedure codes 76800 and 22552 billed for date of service March 16, 2023. You 
say that the records prove medical necessity. The Plan says that the modifier is not supported. 
 
We decided that the Plan has to pay for procedure code 76800.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The Plan denied code 76800 as it is inclusive to procedure code 63081. 
There are no PTP edits found for this code pair for the date of service at issue. Code 76800 was not billed with 
a modifier that indicates the service was distinct or independent from other services. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for procedure code 76800 billed for date of service 
March 16, 2023.  
 
We also decided that the Plan does not have to pay for procedure code 22552. 
 
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 22552 is an add-on code that has not been billed with an appropriate 
primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 22552 billed for date of service March 16, 
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 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 as the enrollee 
is participating and improving with Physical therapy. The Plan denied your request. The Plan says you do not 
meet the criteria for admission to 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 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 6, 2022. 
 You asked the Plan to pay for the ambulance services. You say that the transport was not related to the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on July 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0429 and A0425 (claim 2) provided on 
March 12, 2023. 
 
You asked the Plan to pay for procedure codes A0429 and A0425 (claim 2). You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this claim is a duplicate 
of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 30, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure codes A0429 and A0425 (claim 2) 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A0429 and 
A0425 (claim 2) provided on March 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vitamin D assay test (82306) hemoglobin; glycosylated 
(A1c) (83036) and lipid panel (80061) provided November 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached and reprocess for 
payment. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria and 
laboratory tests completed solely for screening purposes and not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal, procedure codes 82306 and 80061 was requested solely for screening purposes. 
Medicare does not cover these tests solely for screening purposes. The enrollee also does not have a diagnosis 
of diabetes and does not meet the criteria for procedure code 83036. Therefore, we decided that the Plan does 
not have to pay for vitamin D assay test (82306) hemoglobin; glycosylated (A1c) (83036) and lipid panel 
(80061) provided November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J2250 and 96375 provided on April 18, 
2023. 
 
You asked the Plan to pay for procedure codes J2250 and 96375. You say that the medical records support the 
billing of procedure codes J2250 and 96375. The Plan denied your request. The Plan says the medical records 
do not support the billing of procedure codes J2250 and 96375. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J2250 is Injection, midazolam hydrochloride, per 1 mg. 
The definition of code 96375 is Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); 
each additional sequential intravenous push of a new substance/drug (List separately in addition to code for 
primary procedure).  
We find that CPT code J2250 and 96375 is not supported in the medical record. Specifically, the sedation 
record shows that only 2 mg of Versed was administered for code J2250. Additionally, for code 96375, the 
record does not support that any separately reportable IV injections were performed during this encounter. The 
medications administered were included in the main procedures. Based on this information, we decided that 
Medicare rules for coverage of procedure codes J2250 and 96375 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes J2250 and 96375 provided on April 18, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on May 31, 2022. 
 You asked the Plan to pay for the hospital services. You say that the enrollee was not on hospice on this date. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided on May 31, 2022.
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 February 20, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the 
copayment applied is not correct according to you Plan. 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 diagnostic tests. 
 
You have been asked to pay a $250 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. The total you owe is $101.86, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on February 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs physical and occupational therapy. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Nitro Rollator. 
 
You asked the Plan to pre-approve the Nitro Rollator. You say that you need this item. The Plan denied your 
request. The Plan says Medicare doesn't cover brand specific items or duplicate services. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a walker with brake and seat attachment. a walker with brake and seat attachment 
serves the same purpose as the Nitro Rollator. Therefore, we decided that the Plan does not have to pre-approve 
the Nitro Rollator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
October 22, 2022, to October 26, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the enrollee's benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from July 14, 2022, to 
October 21, 2022. The Plan has covered 100 days of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) services provided from October 22, 2022, 
to October 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right hip joint replacement (27130) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve right hip joint replacement with an out-of-network provider. You say that 
this is medically necessary. The Plan denied your request. The Plan says the requested service is available in-
network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
right hip joint replacement (27130) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spironolact. 
 
You asked the Plan to pre-approve Spironolact. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spironolact.  Benefits for Spironolact may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent, genicular nerve 
branches including imaging guidance. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee needs their second 
round of injections. The Plan denied your request. The Plan says the genicular nerve block is not medically 
necessary. The Plan says evidence for a nerve block to treat rheumatoid arthritis is insufficient. 
 
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. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for unilateral primary osteoarthritis of the right knee. The record 
shows there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and a safe treatment for the enrollee's condition. Further studies are needed to corroborate the use of 
genicular nerve blocks are as safe and effective as standard treatment modalities. There is no compelling 
rationale or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested genicular nerve block 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the destruction by neurolytic agent, genicular nerve branches including 
imaging guidance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spineology OptiMesh cage. 
 
You asked the Plan to pre-approve the Spineology OptiMesh cage. You say that the surgery has already been 
scheduled. 
 The Plan denied your request. The Plan says the Spineology OptiMesh cage is not medically necessary. The 
Plan says further studies are needed to evaluate its safety and effectiveness. 
 
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 Spineology OptiMesh cage. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for spondylolisthesis of the lumbar region and 
presented with low back pain with radiation to the bilateral lower extremities. However, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the enrollee's condition. Further studies are needed to demonstrate this request has beneficial 
outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Spineology OptiMesh Cage 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 Spineology OptiMesh cage have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Spineology OptiMesh cage.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs close physician monitoring, 
medication adjustments, from multiple re-admissions. The Plan denied your request. The Plan says that the 
enrollee does not meet the requirements. Services needed may be provided safely in a lower 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found this enrollees condition is in fact complex and fragile, and there is every reason to expect participation 
in services, the requested inpatient rehabilitation is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.