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

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical studies haven't proven this service is helpful. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging shows foraminal stenosis and 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 (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified; amplified probe technique, each organism (87798) provided on December 2, 
2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation does not support 13 units tested: only 10 units of infectious agents are 
supported in the documentation. 
 
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 asked our coder 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 service. Our reviewer found the coding is not supported- 
there are no results for all billed units of service for this line. Code 87798 was billed for 13 units and the 
documentation does not support 13 units tested: only 10 units of infectious agents were supported in the 
documentation. The review has determined that code 87798 was not supported by the records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; 
amplified probe technique, each organism (87798) provided on December 2, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on February 16, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on February 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder arthroplasty (29823) provided on January 6, 2023. 
 
You asked the Plan to pay for shoulder arthroplasty. You say that due to network insufficiency, the out-of-
network provider was the only available assistant at the time of the procedure and rendered services 
specifically requested by the in-network primary physician and in-network facility. The Plan denied your 
request. The Plan says this provider is non-participating and based on specialty and taxonomy is not eligible for 
Medicare. 
   
The Plan must follow Medicare rules. Medicare rules say that Medicare makes payment for an assistant at 
surgery when the procedure is authorized for an assistant and the person performing the service is a physician, 
physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). 
 
We looked at the file and Medicare rules. The services were rendered by a provider who is credentialed as a 
Surgical Assistant. This provider specialty does not have the capacity to bill directly for the services 
rendered. Based on this information, we decided that Medicare rules for coverage of shoulder arthroplasty have 
not been met. Therefore, we decided that the Plan does not have to pay for shoulder arthroplasty (29823) 
provided on January 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Wegovy injection. 
 
You asked the Plan to pre-approve Wegovy. You say that Wegovy is a necessity for your 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Wegovy 
injection.  
 
Benefits for Wegovy 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 12, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the service should be paid. 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 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 January 12, 2023, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve prosthesis additions identified with codes L5828, L5845, L5848, 
and L5856 
 
You asked the Plan to pre-approve prosthesis additions. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the requested items exceed your needs. 
 
The Plan follows Medicare rules. Medicare rules say that prosthesis components are covered for certain 
indications. 
 
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 prosthesis additions. Our reviewer says 
that the documentation does support that the requested items are medically reasonable and necessary. Our 
physician reviewer found you have a right transfemoral amputation. The documentation shows that you are a 
K3 ambulator. The medical record in this case more than meets the standard for documenting your K3-status, 
and then goes above and beyond by describing the requested components particular uses for you. Therefore, 
you meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthesis additions have been met. Therefore, we decided that the Plan has to 
pre-approve prosthesis additions identified with codes L5828, L5845, L5848, and L5856  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ambulance service provided on 
January 09, 2023. 
 
You asked the Plan to waive the coinsurance for the ambulance service. You say that you have insurance and 
should not have to pay for this. 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 20% 
coinsurance for ambulance services. 
 
You have been asked to pay 20% coinsurance for the ambulance service. This item/service falls within the 
ambulance services 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 coinsurance for the ambulance 
service provided on January 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microdissection provided on June 23, 2022. 
 
You asked the Plan to pay for microdissection. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for microdissection 
provided on June 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that you are 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. The requested service 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller upgrade, harness upgrade, and 
electronic connection between wheelchair controller and two or more power seating system motors. 
 
You asked the Plan to pre-approve expandable controller upgrade, harness upgrade, and electronic connection 
between wheelchair controller and two or more power seating system motors. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that your upper limb strength and function 
are adequate for you to be able to control the power options using their own switches which are included in the 
allowance of the approved power options. Based on this information, we decided that Medicare rules for 
coverage of expandable controller upgrade, harness upgrade, and electronic connection between wheelchair 
controller and two or more power seating system motors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve expandable controller upgrade, harness upgrade, and electronic connection 
between wheelchair controller and two or more power seating system motors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on October 25, 2022. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that the services should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic 
visit provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015) provided on 
January 3, 2023. 
 
 You asked the Plan to pay for the eye exam and refraction. You say that this was an eye exam, and you were 
under the impression that the Plan would pay at least $75. You also say that you were under the impression that 
you did not have to meet a deductible first, but this was an eye exam, not a medical procedure, and meeting the 
deductible would not apply. The Plan denied your request. The Plan says the cost sharing for the eye exam was 
charged correctly. The Plan also says that the refraction is not allowed separately. 
 
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 there is a $650 deductible which applies to vision care.  
 
The eye exam you asked the Plan to pay for falls within the vision care benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $650 deductible which applies to vision care. 
This cost sharing is a contractual obligation that had not been met at the time the eye exam was received on 
January 3, 2023.  
 
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 it is completed at the same appointment as a Medicare covered 
comprehensive eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that this was not a routine exam, but a 
medical exam for multiple diagnoses. Based on this information, we decided that the Plan's rules for coverage 
of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam 
(92014) and refraction (92015) provided on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 Sensor. You say that you do not agree with the denial of 
the FreeStyle Libre 2 Sensor. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a FreeStyle Libre 2 Sensor. Our 
reviewer says that the Medicare criteria has not been met. Our physician reviewer found criteria for continuous 
glucose monitor (CGM) coverage require insulin use or low blood sugars. We are not told that this enrollee 
uses insulin nor has low blood sugars. We are also not told why fingerstick monitoring would not suffice for 
this enrollee at this time. Criteria for CGM coverage has not been met. 
 
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 FreeStyle Libre 2 Sensor. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Libre 2 Sensor.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 12, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on September 
13, 2022. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care provided on December 27, 2022, to December 
29, 2022. 
 
You asked the Plan to pay for vision care. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for vision care provided on 
December 27, 2022, to December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on February 06, 2023. 
 
You asked the Plan to pay for initial nursing facility care. You say that the services should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for initial nursing facility 
care provided on February 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784), anti-reflective coating 
(V2750), and deluxe lenses (V2702) provided on January 20, 2023.  
You asked the Plan to pay for polycarbonate lenses, anti-reflective coating, and deluxe lenses. You say that you 
thought these items were covered. The Plan denied your request. The Plan says lens upgrades are not covered. 
 
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. 
 
We looked at the file and the Plan's rules. The Plan contract states that lens upgrades are not covered. Based on 
this information, we decided that the Plan's rules for coverage of polycarbonate lenses, anti-reflective coating, 
and deluxe lenses have not been met. Therefore, we decided that the Plan does not have to pay for 
polycarbonate lenses (V2784), anti-reflective coating (V2750), and deluxe lenses (V2702) provided on January 
20, 2023.