Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization provided from July 12, 2022, to 
July 14, 2022. 
 You asked the Plan to pay for the inpatient hospitalization. The Plan denied your request. The Plan says the 
information received does not support that criterion were met for inpatient hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospitalization. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient has a history of cardiac disease who presented to the hospital with back 
pain for 5 days that extended to their left chest/abdomen. Workup in the emergency department ruled out acute 
coronary syndrome or other serious acute issue. Our reviewer found that the pain was reproducible on palpation 
and suggestive of musculoskeletal cause. Vitals were stable. Our physician reviewer also found that it was not 
expected that the patient would require inpatient services that would have likely crossed 2 midnights, and they 
were not at risk for adverse events.  
 
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 inpatient hospitalization have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospitalization provided from July 12, 2022, to July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (code A4670). 
 
You asked the Plan to pre-approve automatic blood pressure monitor. You say that you need this monitor so 
you can check your blood pressure 2 times per day. The Plan denied your request. The Plan says this item is 
included in the end-stage renal disease (ESRD) benefit for enrollees on home dialysis; however, you do not 
have ESRD and are not on home dialysis. 
 The Plan must follow Medicare rules. Medicare rules say that blood pressure apparatus such as automatic blood 
pressure monitors are considered to be non-medical supplies. Equipment and supplies that are not primarily 
medical in nature are not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of automatic blood pressure monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an automatic blood pressure monitor (code A4670).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service March 31, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the test provides valuable information for 
physicians. The Plan denied your request. The Plan says the coding should not be reported separately. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  The file shows that panel testing was billed with codes 87471, 87481, 87551, 87640, 87641, 87651, 87683, and 
87798. We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic 
acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits 
were used in this case. As such, a single code with one unit of service should be used. Based on this 
information, we decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing billed for date of service March 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revised spinal cord stimulator. 
 
You asked the Plan to pre-approve a revised spinal cord stimulator. You say that a revised spinal cord 
stimulator is medically necessary. The Plan denied your request. The Plan says a revised spinal cord stimulator 
does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is covered when the criteria 
listed in the Medicare rules section of this decision 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 revised spinal cord stimulator. Our 
reviewer says that the requested spinal cord stimulator is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the enrollee has post laminectomy syndrome with continued pain. 
A spinal cord stimulator (SCS) was placed in 2020 and in conjunction with opioids, but only controlling the 
pain 20 percent. The orthopedist states that the SCS is functional without issues. The plan from orthopedic 
surgery is to get a pain pump. Now, the orthopedist wants to reimage the enrollees back with magnetic 
resonance imaging (MRI) to further examine the pathology. There is no reason given why a computed 
tomography (CT) scan will not be helpful. The current SCS battery is not MRI compatible and that is the 
reason for the request to replace the unit. The SCS in functioning properly without indication of failure. Denial 
for the replacement of the SCS is based on the Medicare LCD L36204 trial criteria where the patient isn't 
experiencing a 50 percent reduction of pain and is still using an extensive amount of analgesic medications. 
The request is considered not medically reasonable and necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a revised spinal cord stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a revised spinal cord stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Esophagogastroduodenoscopy provided on February 24, 
2023. 
 
You asked the Plan to pay for the Esophagogastroduodenoscopy. You say that you called your plan and were 
told the procedure was covered unless there was a facility fee. The provider told you they do not charge a 
facility fee. Therefore, you feel that your insurance should pay the claim in full. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that is a $1000 deductible. Until you have paid the deductible amount, you must pay 
the full cost of your covered services. The Plan also says that there is a $245 copayment, after your $1,000 plan 
deductible, for each Medicare-covered outpatient surgery at an ambulatory surgical center. 
 
The item or service you asked the Plan to pay for falls within the outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 
This cost sharing is a contractual obligation that had not been met at the time the Esophagogastroduodenoscopy 
was received on February 24, 2023. At the time of your procedure, you had not met your annual deductible. 
Therefore, we decided that the Plan does not have to pay for the Esophagogastroduodenoscopy provided on 
February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and additional items and 
accessories (codes E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2605, and E2615). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and additional items and accessories. You say 
that you would like the information to be reviewed for approval. The Plan denied your request. The Plan says 
the enrollee does not have a qualifying diagnosis causing mobility limitation for which a Group 3 power 
wheelchair is medically needed. The enrollee has no medical need for multiple power options included with the 
requested power wheelchair. The Plan also says the expandable controller, harness, and electronics are not 
medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with Single 
Power Option or with Multiple Power Options is covered if the criteria listed in the Medicare rules section of 
this letter are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be 
denied. 
 
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 3 power wheelchair and 
additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has diabetes, obesity and history of a femur fracture. The enrollee is able 
to perform self-care independently and they can stand and transfer independently. Our reviewer also found that 
the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require 
an alternative means of managing power drive. 
 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 3 power wheelchair and additional items and accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and 
additional items and accessories (codes E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, 
E2605, and E2615).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
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 requested service is 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for lumbago with sciatica on the right side and vertebrogenic low 
back pain. She presented with back pain as well as left hip, thigh, knee, and leg pain. The pain is aggravated by 
recumbency, standing, walking, driving, and lifting. She has numbness and tingling.  
  
The exam reveals tenderness to palpation over the midline and paraspinal musculature at the L4 and L5 levels 
as well as left posterior superior iliac spine (PSIS) and greater trochanter. There is decreased range of motion. 
Sensation, strength, and reflexes are intact. The seated slump test is positive on the left as is the supine straight 
leg raise. The Kemps test is positive bilaterally. In this case, there are multiple plausible pathologic sources of 
significant pain generation. The back pain, the noted pain-aggravating factors (recumbency, standing, walking, 
driving, and lifting), the diminished spinal motion, and intact neurologic exam are all non-specific to any 
pathologic entities. 
 
Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the 
spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Intracept intraosseous basivertebral nerve ablation at L5 and S1, in this case, 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. You say that you need this service because you are 
experiencing pain. The Plan denied your request. The Plan says a sacroiliac joint injection is 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 the injection. Our reviewer says that a 
sacroiliac joint injection is not medically necessary. Our physician reviewer found that you have multiple 
untreated sacral fractures and are not on Vitamin D, calcium supplements or romosozumab. Therefore, the 
requested procedure is not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF care provided from June 30, 2023, to July 29, 2023. 
 You asked the Plan to pay for the SNF care. You say that services which the enrollee required and received 
during the period in question are coverable. The Plan denied your request. The Plan says the enrollee had no 
daily skilled nurse or therapy needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the SNF care provided from June 30, 2023, to July 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that this was medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 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 the office visit provided on July 25, 2023, by an 
out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 You asked the Plan to pre-approve Leqvio. You say that the enrollee cannot tolerate statins due to muscle 
aches. You say the enrollee has a fear of needles and is not able to self-inject; therefore, you are requesting a 
nurse administer Leqvio. The Plan denied your request. The Plan says step therapy requirements have not been 
met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Leqvio. Our reviewer says that the 
criteria for coverage of Leqvio have not been met. Our physician reviewer found the Plan requires a trial of 
Praluent before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the Plans required drug would likely be less 
effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skin procedure provided on December 
30, 2022. 
 
You asked the Plan to waive the copayment for the skin procedure. You say that you say that your Explanation 
of Benefits (EOB) states that you reached your MOOP amount prior to these services. 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 
copay for each Medicare-covered outpatient surgery at an outpatient hospital facility. 
 
The record shows the original EOB was processed incorrectly showing that you had meet your MOOP amount. 
The Plan has corrected this error to show that you had not met your MOOP amount at the time of service. You 
have been asked to pay $180.40, which is less than the standard copayment for the skin procedure. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 
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 the skin procedure provided on 
December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the combined Hepatitis A and B vaccines (Twinrix) and 
administration provided from March 23, 2023, to April 24, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that you cannot afford to pay for these out-of-
pocket and then wait for reimbursement. You say that you did not know that you needed to have these done at a 
pharmacy. You also say that your doctor told you that you needed the shots. The Plan denied your request. The 
Plan says the vaccine services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the combined Hepatitis A and B vaccines 
(Twinrix) and administration provided from March 23, 2023, to April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) provided on 
July 12, 2023. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you don't understand why 
this service was not covered. The Plan denied your request. The Plan says any services performed that are not 
covered are your responsibility at the dentists usual fees. 
 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D 
oral/facial photographic image (D0350) provided on July 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93005 billed for date of service March 10, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the code is payable under Medicare guidelines. 
The Plan denied your request. The Plan says the code is not separately payable. 
 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 93005 has a status indicator of Q1. This code is packaged into payment for service with 
a status indicator of V, such as billed code 99283. Based on this information, we decided that Medicare rules 
for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 93005 billed for date of service March 10, 2023.