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

 
We decided that the Plan does not have to pre-approve exploration of spinal fusion for L5-S1 posterior lumbar 
fusion. 
 
You asked the Plan to pre-approve spinal fusion exploration. You say that the enrollee has completed physical 
therapy. The Plan denied your request. The Plan says code 22830 is a column 2 code to column 1 code 22630 
so it not separately reimbursable. 
 
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 spinal fusion exploration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found exploration of spinal fusion cannot be billed at the same level as a fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion exploration have not been met. Therefore, we decided that the 
Plan does not have to pre-approve exploration of spinal fusion for L5-S1 posterior lumbar fusion.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 6 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the health plan. The records do 
not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the enrollee's current condition or to prevent or slow further deterioration. The enrollee 
has had extensive therapy and has had instruction in a home exercise program. The requested additional 
therapy sessions do not require ongoing skilled professional therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 6 physical therapy (PT) visits.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service July 19, 
2022. 
 You asked the Plan to pay for procedure code 99284. The Plan denied your request. The Plan says payment for 
code 99284 is bundled into payment for code 99285. 
 
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 99284 
is a column II code to column I code 99285. 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 code 99284 billed for date of service July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies not used with external infusion pump 
(A4223), disposable drug delivery system (A4305), and heparin sodium (J1642) provided from November 16, 
2022, to November 22, 2022. 
 
You asked the Plan to pay for the disposable drug delivery system and supplies. You say that the enrollee's 
plan guidelines indicate A4223 and A4305 are applicable codes and does not imply the codes are not covered. 
The Plan denied your request. The Plan says disposable drug delivery systems are non-covered devices. The 
Plan also says related drugs and supplies are not covered too. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. Drugs and supplies used with disposable drug delivery 
systems are also non-covered items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the infusion supplies not used with external infusion pump (A4223), disposable drug delivery system 
(A4305), and heparin sodium (J1642) provided from November 16, 2022, to November 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of Keytruda infusions. 
 
You asked the Plan to pre-approve the continued use of Keytruda infusions. You say that the continued use of 
Keytruda infusions are medically necessary. The Plan denied your request. The Plan says the continued use of 
Keytruda infusions are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
  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 continued use of Keytruda 
infusions. Our physician reviewer says that the requested use of Keytruda is not Food and Drug 
Administration-approved for the enrollee's diagnosis and is not supported by one of the major drug compendia 
or by a CMS-approved medical journal. The record indicates that the enrollee has received over 60 months of 
the requested therapy. The continued use of Keytruda in this case cannot be recommended. 
 
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 continued use of Keytruda infusions have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continued use of Keytruda infusions.
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 need rehab for your leg in order to build strength 
to return home. The Plan denied your request. The Plan says the IRF services you are requesting do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 pay for procedure code A4206 provided on November 26, 2022. 
 
You asked the Plan to pay for procedure code A4206. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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. 
 
CPT code A4206 has a status code of "X" under the MPFSDB and represents a service that is not in the 
statutory definition of "physician services" for fee schedule payment purposes. Therefore, we decided that the 
Plan does not have to pay for procedure code A4206 provided on November 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that you need this to be in less pain. The Plan denied 
your request. The Plan says there is insufficient evidence of efficacy. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex procedure 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure does not meet the standard of 
care because the radiologic studies show additional significant pathologies such as spinal stenosis and facet 
arthropathy that are unlikely to benefit from the procedure. 
 
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 Intracept procedure. Our reviewer 
says that the requested the Intracept procedure is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is no magnetic resonance imaging showing only Modic endplate 
changes without facet joint syndrome or foraminal stenosis. The cause of back pain is not clear. 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the frame and lens provided on January 28, 2023.

You asked the Plan to pre-approve the frame and lens. You say that the item should be covered. The Plan denied your request. The Plan says the maximum benefit for this item has been exhausted.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when here is a $200 benefit toward the purchase and fitting of eyeglasses and a pair on lenses or contact lenses per a calendar year.

We looked at the file and the Plan's rules. You have exceeded the maximum allowance for this item and are responsible for the remaining amount. Based on this information, we decided that the Plan's rules for coverage of the frame and lens have not been met. Therefore, we decided that the Plan does not have to pre-approve the frame and lens provided on January 28, 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 
from October 7, 2022, to October 26, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that this is a medical necessity 
appeal based on the medical literature and efficacy of the treatment rendered. The Plan denied your request. 
The Plan says the requested the water circulating heating pad with pump is non-covered because it is not 
considered reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0217 is provided it will be denied as not 
reasonable and necessary. 
 We looked at 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 from October 7, 2022, to 
October 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on September 22, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and were ordered by the 
enrollee's physician. The Plan denied your request. The Plan says there is insufficient documentation for these 
services. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 drug testing have been met. 
Specifically, the physician order in this case has an illegible signature. The one page of physician notes does 
not mention any intent to have this testing performed, nor is there any documentation to support the medical 
necessity of this testing. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) 
provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 1, 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 service is not a covered benefit. 
 
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 dental 
services on February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the requested Intracept procedure 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 Intracept procedure. Our reviewer 
says that the requested the Intracept procedure is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is no magnetic resonance imaging showing only Modic changes 
without facet joint syndrome or foraminal stenosis. The cause of back pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary and are supported in the medical record. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic and retainer crown (D6240, D6750). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
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 
services 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 pre-approve the dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the documentation provided does 
not meet the criteria for coverage 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic and retainer crown (D6240, D6750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800).  

You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there was no home evaluation provided to indicate your home provides 
adequate access between rooms, maneuvering space, and surfaces for the operation of the POV. 
 
The Plan must follow Medicare rules. Medicare rules say that a POV may be covered if the beneficiary's 
home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV 
that is provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power scooter (K0800).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that Prolia is a medical necessity for you. The Plan denied 
your request. The Plan says step-therapy rules for coverage of Prolia 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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial 
of oral osteoporosis drugs before they will approve the requested drug. In this case, you have not tried and 
failed the required drugs. There is no documentation provided indicating that the Plans required drugs would 
likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99291 provided on December 21, 2022.

You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

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 procedure code 99291 have been met. In this case, the Plan made multiple attempts to obtain medical records which were never received. Therefore, we decided that the Plan does not have to pay for procedure code 99291 provided on December 21, 2022.