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

 
We decided that the Plan does not have to pay for the ambulance services provided on December 8, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not yet on hospice at the 
time of services. 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 the ambulance services provided on December 8, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary The Plan denied your request. The Plan says that the services are not medically necessary. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc (0627T). 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found this is 
considered an experimental/investigational procedure.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc (0627T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 31, 2023, through February 
16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on January 31, 2023, through February 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on October 13, 2022, through October 27, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item 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.  If code E0215 or E0217 is provided it will be denied as not 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 pay for the water circulating heat pad with pump. 
Our reviewer says that  Our physician reviewer found  
 
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 water circulating heat pad with pump have not been met. Therefore, we 
decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided on 
October 13, 2022, through October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prolia injection provided on October 18, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the Prolia injection. You say that this service should be covered. 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 service at 
issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the 
Plan does not have to pay for the Prolia injection provided on October 18, 2022, by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix skin substitute (Q4186). 
 
You asked the Plan to pre-approve Epifix skin substitute. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because the records show the enrollee 
has not tried four weeks of standard wound therapy. No measurements over a 30-day period were provided. 
 
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 Epifix skin substitute. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided record does not document the failure of standard wound therapy. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 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 Epifix skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Epifix skin substitute (Q4186).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3-L5 kyphoplasty (22512, 22514). 
 
You asked the Plan to pre-approve L3-L5 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial 
with multilevel disc disease. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific 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 L3-L5 kyphoplasty. Our reviewer says 
that you do not meet coverage criteria. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. Additionally, the magnetic resonance imaging (MRI) does not corroborate an acute 
or subacute fracture at all of the requested levels. The fractures were noted to be present on the April 25, 2023, 
MRI and no indication if they were present prior to that (as you note back pain for 12 months). There is no 
indication of a progression of your daily activities. Moreover, there is MRI corroboration of plausible other 
causes of back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3-L5 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve L3-L5 kyphoplasty (22512, 22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from October 25, 2022, to 
November 4, 2022. 
 
You asked the Plan to pay for the medication. You say that you only took your prescription medications while 
in the hospital. 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 pay for self-administered drugs provided 
from October 25, 2022, to November 4, 2022.  
 
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the CGM have been met. There was no 
medical documentation submitted to prove the medical necessity or the Medicare coverage criteria was met for 
the CGM. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from December 2, 2021, to December 31, 2021.  
 
You asked the Plan to waive the copayments for the PT services. You say that the bills should have been paid 
by the enrollee's supplemental insurance. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $5 copayment for outpatient rehabilitation services.  
 
 
  The enrollee has been asked to pay a $5 copayment for each of the 13 PT services. The total owed is $65 ($5 
copayment x 13 visits = $65). This item/service falls within the outpatient rehabilitation services benefit 
category. The record does not show that the enrollee was enrolled in a supplemental plan. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for physical therapy (PT) services provided from December 2, 2021, to 
December 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vacuum assisted suspension system (VASS) L5781). 
 
You asked the Plan to pre-approve the vacuum socket system . You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the request for this 
residual limb volume management system exceeds the enrollee's need and does not meet the Medicare criteria of 
reasonable and necessary. 
 
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. The use of vacuum pumps for residual limb volume management and 
moisture evacuation systems among amputees is unproven and not medically necessary due to insufficient 
evidence of safety and/or efficacy. There are only a few publications in the literature that examine the efficacy 
of the VASS. Based on this information, we decided that Medicare rules for coverage of the vacuum socket 
system have not been met. Therefore, we decided that the Plan does not have to pre-approve the vacuum 
assisted suspension system (VASS) L5781).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (27280). 
 
You asked the Plan to pre-approve SI joint fusion. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of an open SI joint fusion procedure in the 
setting of clinical documentation that does not demonstrate any evidence of sacroiliac joint instability, fracture, 
or tumor presence have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SI joint fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no SI joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (27280).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code is 
not supported. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of moderate complexity.  
 
We find that CPT code 99222 is not supported in the medical record. Specifically, a comprehensive history was 
not included on the date of service at issue. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99222 billed for date of service March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NeuraGen (64910). 
 
You asked the Plan to pre-approve NeuraGen. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve NeuraGen. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found NeuraGen is not medically reasonable and necessary in this case. The use of NeuraGen with radical prostatectomy is still considered to be experimental. There have been very limited studies in the setting 
of radical prostatectomy and 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 NeuraGen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve NeuraGen (64910).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous device (C1821). 
 
You asked the Plan to pre-approve an interspinous device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show that the requested device has a clear role in the 
treatment of the enrollee's condition. 
 
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 interspinous device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found interspinous devices are experimental in spine surgery. 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 an interspinous device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous device (C1821).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81292, 81295, 81298 and 81317 billed for 
date of service January 10, 2023. 
 
You asked the Plan to pay for procedure codes 81292, 81295, 81298 and 81317. You say that these services 
were reported appropriately and are supported in the medical record. The Plan denied your request. The Plan 
says payment for codes 81292, 81295, 81298 and 81317 is bundled into payment for code 81455. 
 
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 codes 
81292, 81295, 81298 and 81317 are column II codes to column I code 81455. This claim has not been billed 
with an appropriate modifier to bypass the edit. 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 codes 81292, 81295, 
81298 and 81317 billed for date of service January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 30, 2022, billed 
with codes 99204, 94760, and 93770. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid as billed.  The Plan denied 
your request. The Plan says the codes at issue were denied correctly.  
 
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 99204 
is a column II code to column I code 94760. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, code 93770 has a status indicator of B on the Physician Fee Schedule. This means 
that payment is bundled with other services. Code 94760 has a status indicator of T, meaning it can only be 
paid if it is the only code on the claim. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 
30, 2022, billed with codes 99204, 94760, and 93770.