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

 
We decided that the Plan does not have to pre-approve  the placement of Vertiflex interspinous process spacers 
at two lumbar spinal levels (22869, 22870).  
 
You asked the Plan to pre-approve a Vertiflex device. You say that  the enrollee would benefit from this 
procedure because he does not have any spinal instability, no remarkable scoliosis, or severe osteoporosis, and 
would like to avoid more invasive procedures, such as a laminectomy or a spinal fusion.  The Plan denied your 
request. The Plan says the requested placement of Vertiflex interspinous process spacers at two lumbar spinal 
levels is not appropriate and does not meet coverage criteria based on lack of medical necessity for the service.  
 
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 placement of a Vertiflex device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of Vertiflex interspinous process spacers at two lumbar spinal levels 
have not been met. Therefore, we decided that the Plan does not have to pre-approve  the placement of 
Vertiflex interspinous process spacers at two lumbar spinal levels (22869, 22870).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care (99283) provided on November 26, 
2022. 
 
You asked the Plan to pay for the emergency care. The Plan denied your request. The Plan says the claim was 
billed with the incorrect place of service. 
 
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 find that payment for CPT code 99283 is not supported in the medical record. Specifically, the records 
show that the emergency department visit was billed with place of service (POS) 49, an independent clinical. 
As code 99283 represents an emergency department visit, it is inappropriate to bill this code without an 
emergency department POS code. Based on this information, we decided that Medicare rules for coverage of 
the emergency care have not been met. Therefore, we decided that the Plan does not have to pay for the 
emergency care (99283) provided on November 26, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental service (D2332) on December 14, 2022, through December 
20, 2022. 
 
You asked the Plan to pay for the dental service (D2332). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says that the criteria for approval 
have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
service (D2332) when the services are medically necessary and reasonable. 
 
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 dental service (D2332). Our reviewer 
says that the service is medically necessary. Our physician reviewer found the documentation provided meets 
the criteria for coverage for resin-based composite, three surfaces (D2332) for teeth 8, 10 and 11. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service (D2332) have been met. Therefore, we decided that the Plan 
has to pay for the dental service (D2332) on December 14, 2022, through December 20, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9379 billed for date of service December 
31, 2022. 
 
You asked the Plan to pay for procedure code S9379. You say that this is the correct per diem code. 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 S9379 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9379 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9379 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9379 billed for date of service December 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on November 30, 
2022. 
 
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used 
when two conditions cannot occur together.  
 
We looked at the file and Medicare rules. The claim in this case was billed with diagnosis code R11.0 and 
K92.0. Diagnosis code R11.0 has an Excludes1 notes and is not payable when billed with diagnosis code 
K92.0. Based on this information, we decided that Medicare rules for coverage of the transportation have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided 
on November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions. 
 
You asked the Plan to pre-approve facet joint interventions. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee does not meet criteria for this request. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered if 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 facet joint interventions. Our reviewer 
says that the enrollee does not meet criteria for this procedure. Our physician reviewer found the enrollee has a 
history of lumbar radiculopathy. Physical examination and imaging results were not included in the request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint interventions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing for 15-21 drug classes rendered 
on October 28, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in 
clinical management, exceeds the needs of the enrollee. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there was sufficient information to manage the enrollee without definitive testing. The records show 
that the enrollee is taking a medication with abuse potential for which there was no presumptive test 
commercially available. The review has determined that the enrollee did not meet the criteria for this testing. 
The enrollee did not need 15-21 drug classes tested. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive urine drug testing for 15-21 drug classes rendered on October 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been on Ozempic with no 
issues since March, 2023. You say the enrollee tolerates Ozempic very well, and you find it necessary for this 
medication to be continued in this enrollee's care. 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 Ozempic.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (scooter) 
(K0800). 
 
You asked the Plan to pre-approve a scooter. The Plan denied your request. The Plan says you have the 
strength to self- propel a manual wheelchair, and the Medicare criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 scooter. Our reviewer says that a 
scooter is not medically reasonable and necessary for you. Our physician reviewer found the enrollee has a 
neuropathy but is able to walk with a rollator. Our reviewer also found that you do not require a scooter to 
achieve MRADLs in the home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 1 standard power operated vehicle (scooter) (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Reblozyl. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of  anemia in the setting of moderate risk myelodysplastic 
syndrome without documentation of ringed sideroblasts. The Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved  drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements 
of the coverage criteria are not satisfied. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service January 15, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 find that CPT code 99233 is not supported in the medical record. Specifically, this code was billed with 
primary diagnosis R65.20 (Severe sepsis without septic shock). This diagnosis code has a code first note 
meaning that the underlying condition should be sequenced first. The claim is not payable as billed. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99233 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99233 for date of service January 
15, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a selective catheter placement, arterial system; initial third order or 
more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family (36247). 
 You asked the Plan to pre-approve abdominal aortography/ angiography. You say that the Plan has approved 
this procedure previously with no problem as recently as this past April with your doctor. You chose this route 
over a surgical procedure and has been scheduled 3 times over the past 6 weeks and all have been held up 
waiting on an authorization from the Plan. The Plan denied your request. The Plan says that the request is not 
medically necessary because the records show the interventional procedure for which the catheter placement is 
being requested is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve abdominal aortography/ angiography. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found you have an enlarged prostate at 76 cc and there is a request for prostatic 
artery embolization. This treatment has proven to be an effective means by which to shrink the prostate gland 
without surgery. The technique has been used for several years and its use has been supported in the medical 
literature and should be 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 abdominal aortography/ angiography have been met. Therefore, we decided that 
the Plan has to pre-approve a selective catheter placement, arterial system; initial third order or more selective 
abdominal, pelvic, or lower extremity artery branch, within a vascular family (36247).  
 
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 you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the request for an IRF admission does 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the OON second opinion. You say that you would like to receive a second 
opinion OON because in-network providers will be biased and not want to contradict their peers.  The Plan 
denied your request. The Plan says the services are available from network providers.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services with an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service December 
19, 2022.  
 
You asked the Plan to pay for procedure code 99232. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99232 is bundled into payment for code 99239. 
 
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 99232 is a column II code to column I code 99239 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99232 billed for date of service December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Guardant360 TissueNext test rendered on 
September 23, 2022. 
 
You asked the Plan to pre-approve the services. You say that the test was medically necessary. The Plan denied 
your request. The Plan says the records do not show non-small cell lung cancer. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this testing has not been approved or cleared by the FDA for use in patients with non-small cell lung 
cancer. Further, there are no documentation of how extensive and advanced the lung adenocarcinoma is in this 
case to see if this is refractory, recurrent, or advanced lung adenocarcinoma. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Guardant360 TissueNext test rendered on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopedic slippers. 
 
You asked the Plan to pay for the orthopedic slippers. You say that the item should be covered. The Plan 
denied your request. The Plan says this item is not medical in nature and not allowed under the wellness wallet 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a plans may choose to offer some benefits to 
enrollees in addition to the covered Medicare Part A and Part B (and Part D, as applicable) benefits they are 
required to offer if the item or service also meets the criteria described in sections 30 and 40 of this chapter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthopedic slippers have not been met. Therefore, we decided that the Plan does not have to 
pay for the orthopedic slippers.